Inspection Reports for
Pueblo Heights Nursing and Rehabilitation
1601 CONSTITUTION RD, PUEBLO, CO, 81001-2132
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Census: 46
Deficiencies: 13
Date: Jul 18, 2024
Visit Reason
Routine state inspection of Pueblo Heights Nursing and Rehabilitation to assess compliance with regulatory requirements including resident rights, medication administration, infection control, pressure injury prevention, food service, and facility maintenance.
Findings
The facility had multiple deficiencies including failure to ensure resident rights and dignity, medication administration errors, inadequate infection control practices, failure to prevent pressure injuries, poor food quality and temperature control, and maintenance issues compromising safety and comfort.
Deficiencies (13)
F 0550: The facility failed to ensure Resident #25 was provided with incontinence supplies, resulting in dignity concerns.
F 0554: The facility failed to ensure Resident #5 was assessed for safe self-administration of all medications, including pills.
F 0558: The facility failed to ensure Resident #289's bathroom call light was consistently accessible to accommodate his mobility needs.
F 0600: The facility failed to protect Resident #23 from sexual abuse by Resident #65 and did not properly document or follow up on the incident.
F 0676: The facility failed to ensure Resident #13 received assistance with activities of daily living including dressing, hygiene, and eating according to her care plan.
F 0679: The facility failed to provide individualized, purposeful activities for Resident #62, who was cognitively impaired and dependent.
F 0686: The facility failed to implement timely interventions to prevent Resident #84 from developing a Stage 2 pressure injury and delayed care plan implementation.
F 0759: The facility failed to ensure medication administration was free from errors including failure to prime insulin pen and missed eye drop administration.
F 0760: The facility failed to ensure insulin pen was primed prior to administration for Resident #290, risking incorrect dosing.
F 0761: The facility failed to ensure medications were properly stored and labeled, including expired medications and a vial of Tubersol not discarded after 30 days.
F 0804: The facility failed to ensure residents consistently received food that was palatable in taste, texture, and temperature.
F 0880: The facility failed to implement and follow enhanced barrier precautions for residents with wounds or indwelling devices, failed to properly clean resident rooms, and failed to cover residents' laundry during transport.
F 0921: The facility failed to maintain a safe, functional, sanitary, and comfortable environment due to maintenance issues in resident rooms, hallways, and shower rooms.
Report Facts
Medication administration error rate: 9.68
Resident sample size: 46
Pressure injury wound size: 2
Tubersol vial discard timeframe: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to prime insulin pen and forgot to administer eye drops |
| RN #1 | Registered Nurse | Observed expired medications and medication storage issues |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, pressure injury prevention, and infection control |
| NHA | Nursing Home Administrator | Interviewed regarding overall facility deficiencies and maintenance issues |
| CNA #5 | Certified Nursing Aide | Witnessed sexual abuse incident between residents #65 and #23 |
| Wound Physician | Physician | Assessed pressure injury for Resident #84 |
| Housekeeping Director | Housekeeping Director | Interviewed regarding cleaning procedures and laundry transport |
| Dietary Manager | Dietary Manager | Interviewed regarding food quality complaints and meal service |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Feb 16, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, environment, medication management, food safety, immunizations, and COVID-19 testing.
Findings
The facility was found deficient in multiple areas including environmental maintenance, resident care assessments, accident prevention, medication labeling and storage, food safety and hygiene, immunization policies, and COVID-19 testing documentation. Deficiencies were generally of minimal harm but affected multiple residents.
Deficiencies (7)
F 0584: The facility failed to maintain a sanitary, orderly, and comfortable environment in 18 of 61 resident rooms, including damaged walls, missing transition strips, non-functioning ventilation fans, and sticky floors.
F 0684: The facility failed to assess Residents #47 and #70 after changes in condition, lacking evidence of timely nursing assessments and provider notifications.
F 0689: The facility failed to ensure adequate supervision and accident hazard prevention for Residents #68 and #15, including lack of wander guard monitoring and ineffective fall interventions.
F 0761: The facility failed to ensure drugs and biologicals were properly labeled and stored, including expired and undated medications and loose pills in medication carts.
F 0812: The facility failed to ensure appropriate hand hygiene by food service staff and maintain cutting boards free from deep scratches and stains.
F 0883: The facility failed to develop and implement policies and procedures to ensure residents were offered pneumococcal immunizations, with no evidence of offer or refusal for Residents #10 and #69.
F 0886: The facility failed to document COVID-19 test results in resident records for five reviewed residents, inconsistent with current standards of practice.
Report Facts
Resident rooms with environmental deficiencies: 18
Residents reviewed for vaccinations: 29
Residents reviewed for COVID-19 testing: 5
Residents affected by environmental deficiencies: 18
Residents affected by care assessment deficiencies: 2
Residents affected by accident hazard deficiencies: 2
Residents affected by medication labeling deficiencies: 1
Residents affected by food safety deficiencies: Many
Residents affected by immunization policy deficiencies: 2
Residents affected by COVID-19 testing documentation deficiencies: 5
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Nov 4, 2021
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare facility standards and resident care requirements.
Findings
The facility was found deficient in honoring resident self-determination regarding shower preferences, providing appropriate respiratory care, addressing psychosocial support and behavior management, ensuring proper use and review of psychotropic medications, and maintaining proper labeling and storage of medications.
Deficiencies (5)
F 0561: The facility failed to honor resident choices for shower frequency and scheduling for two residents, resulting in inconsistent shower provision contrary to resident preferences.
F 0695: The facility failed to ensure oxygen therapy was administered according to physician orders for one resident, including improper oxygen concentrator settings.
F 0742: The facility failed to provide psychosocial support and develop a behavior plan to reduce incontinence-related behaviors for one resident.
F 0758: The facility failed to ensure a PRN antipsychotic medication was reviewed every 14 days and lacked individualized non-pharmacological care plans for one resident.
F 0761: The facility failed to date opened insulin vials, identify ownership of insulin vials, discard expired nitroglycerin tablets, and date opened tuberculin and inhaler medications in medication carts and storage rooms.
Report Facts
Residents reviewed: 35
Shower refusals: 3
Incontinence incidents: 32
PRN Haldol doses: 9
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