Inspection Reports for
The Center at Park West LLC
3727 PARKER BLVD, PUEBLO, CO 81008, CO
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 23, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to resolve grievances, inadequate baseline care plans, insufficient assistance with activities of daily living, improper wound care, and inadequate dementia care.
Complaint Details
The complaint investigation substantiated multiple deficiencies including failure to resolve grievances, inadequate baseline care plans, insufficient assistance with ADLs, improper wound care, and inadequate dementia care.
Findings
The facility failed to promptly resolve grievances, develop and implement baseline care plans, provide adequate assistance with activities of daily living, properly monitor and treat wounds including pressure injuries, and deliver person-centered dementia care. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (6)
F 0585: The facility failed to ensure prompt efforts to resolve grievances for Resident #2, including inadequate documentation and unsatisfactory responses to concerns about physical therapy.
F 0655: The facility failed to develop and implement a person-centered baseline care plan within 48 hours of admission for Residents #2, #8, and #17, lacking key interventions and documentation of care plan acknowledgement.
F 0677: The facility failed to provide necessary assistance with activities of daily living for Residents #3 and #7, including inconsistent meal assistance and bathing.
F 0684: The facility failed to provide timely, consistent, and effective wound care for Residents #1 and #5, resulting in Resident #1's hospitalization for an infected amputation site and delayed wound care orders for Resident #5.
F 0686: The facility failed to accurately identify, document, and treat a pressure injury for Resident #9 and failed to consistently monitor and implement wound prevention interventions for Residents #7 and #9.
F 0744: The facility failed to provide appropriate person-centered dementia care for Residents #17, #5, and #3, including lack of individualized care plans, insufficient activities, and inadequate behavioral management.
Report Facts
Residents in sample: 17
Residents affected by grievance deficiency: 1
Residents affected by baseline care plan deficiency: 3
Residents affected by ADL assistance deficiency: 2
Residents affected by wound care deficiency: 2
Residents affected by pressure ulcer care deficiency: 2
Residents affected by dementia care deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Mentioned in relation to failure to assist Resident #3 with eating and hygiene |
| LPN #1 | Licensed Practical Nurse | Mentioned in relation to wound care and Resident #3's supervision |
| WCN #1 | Wound Care Nurse | Mentioned in relation to wound care deficiencies for Residents #5 and #7 |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including grievance resolution, care plans, wound care, and dementia care |
| SSD | Social Services Director | Interviewed regarding dementia care and grievance process |
| AD | Activities Director | Interviewed regarding dementia care activities |
| NP #1 | Nurse Practitioner | Interviewed regarding wound care and notification |
| RN #1 | Registered Nurse | Interviewed regarding wound care and Resident #5 admission |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding wound care and air mattress settings |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding Resident #17 behavior and wandering |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident privacy and confidentiality of medical records, and to evaluate the adequacy of pain management for residents.
Findings
The facility failed to keep residents' medical records confidential by not ensuring nursing staff logged off workstations, exposing resident information. Additionally, the facility failed to provide effective pain management for a resident, including incomplete pain assessments, lack of documented non-pharmacological interventions, and inconsistent medication administration documentation.
Deficiencies (2)
F 0583: The facility failed to keep residents' personal and medical records private and confidential by not ensuring nursing staff logged off their workstations when leaving the work area, exposing resident electronic medical records to unauthorized viewing.
F 0697: The facility failed to provide safe, appropriate pain management for Resident #32 by not completing comprehensive pain assessments, not offering or monitoring non-pharmacological interventions, and inconsistently documenting administration of pain medications.
Report Facts
Sample residents reviewed: 40
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in observations and interviews regarding failure to log off workstations and pain assessment duties |
| CNA #5 | Certified Nurse Aide | Interviewed regarding confidentiality practices and pain management interventions |
| RN #1 | Registered Nurse | Interviewed regarding pain assessment and management practices |
| NHA | Nursing Home Administrator | Interviewed regarding confidentiality practices |
| DON | Director of Nursing | Interviewed regarding confidentiality and pain management practices |
Inspection Report
Deficiencies: 6
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, hospice services, staff training, and confidentiality of medical records.
Findings
The facility was found deficient in multiple areas including failure to keep medical records confidential, inadequate investigation and prevention of a resident's skin tear, ineffective pain management for a resident, failure to monitor and provide appropriate interventions for psychotropic medication use, lack of hospice care plan initiation, and failure to ensure annual dementia and abuse training for certified nurse aides.
Deficiencies (6)
F 0583: The facility failed to keep residents' medical records confidential by not ensuring nursing staff logged off workstations when leaving, exposing resident EMRs to unauthorized viewing.
F 0689: The facility failed to conduct a thorough investigation and identify the root cause of a skin tear sustained by Resident #32 during a staff-assisted transfer, and did not implement immediate interventions to prevent recurrence.
F 0697: The facility failed to provide effective pain management for Resident #32 by not completing comprehensive pain assessments, not offering or monitoring non-pharmacological interventions, and inconsistent documentation of pain medication administration.
F 0758: The facility failed to ensure Resident #98's hours of sleep were documented for psychotropic medication use and did not identify or attempt person-centered interventions for repetitive statements prior to ordering antipsychotic medication.
F 0849: The facility failed to initiate a hospice care plan for Resident #19 receiving hospice services, resulting in unclear responsibility for resident care between facility and hospice staff.
F 0947: The facility failed to ensure certified nurse aides #3, #4, and #5 completed annual dementia and abuse training as required.
Report Facts
Residents reviewed: 40
Skin tear size: 4.5
Skin tear size: 1
BIMS score: 14
BIMS score: 6
BIMS score: 6
Melatonin dose: 1
Seroquel dose: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to confidentiality and pain management |
| CNA #5 | Certified Nurse Aide | Named in findings related to confidentiality and pain management |
| RN #1 | Registered Nurse | Named in findings related to pain management and resident care |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including confidentiality, skin tear investigation, pain management, psychotropic medication monitoring, hospice care plan, and staff training |
| MDSC | Minimum Data Set Coordinator | Interviewed regarding hospice care plan and care plan implementation |
| NHA | Nursing Home Administrator | Interviewed regarding abuse training and confidentiality |
Inspection Report
Deficiencies: 0
Date: Mar 2, 2023
Visit Reason
The inspection was conducted as a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 8
Date: Jan 6, 2022
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements including resident rights, respiratory care, pain management, dementia care, medication use, nutrition, infection control, and COVID-19 testing procedures.
Findings
The facility was found noncompliant in multiple areas including failure to ensure residents' visitation rights, improper oxygen administration, inadequate pain management, insufficient dementia care interventions, failure to evaluate PRN psychotropic medication use timely, failure to follow menus and food extensions, lapses in infection prevention and control practices including hand hygiene and equipment disinfection, and improper COVID-19 testing procedures for visitors and staff.
Deficiencies (8)
F 0563: Facility failed to ensure residents' right to receive visitors of their choosing at the time of their choosing, limiting visitation except for hospice and compassionate care visits.
F 0695: Facility failed to administer oxygen according to physician orders for three residents, including improper titration and documentation.
F 0697: Facility failed to follow pain medication parameters, complete weekly comprehensive pain evaluations, and implement non-pharmacological interventions prior to PRN pain medication for two residents.
F 0744: Facility failed to provide appropriate dementia care by not implementing person-centered and non-pharmacological interventions to address dementia care needs for one resident.
F 0758: Facility failed to re-evaluate PRN psychotropic medication use by a physician within 14 days and failed to document non-pharmacological interventions prior to administration for one resident.
F 0803: Facility failed to follow menus, omitted menu items without substitutions of equal nutritional value, and did not follow pureed and mechanical soft diet extensions.
F 0880: Facility failed to perform hand hygiene before and after resident contact, failed to offer hand hygiene to residents before meals, and failed to disinfect equipment between resident use.
F 0886: Facility failed to follow infection control measures during COVID-19 testing of visitors and staff, including failure of front desk staff to wear proper PPE and conduct testing in a secure area.
Report Facts
PRN Lorazepam administrations: 27
Pain medication administrations outside parameters: 4
Pain level scores: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Interviewed regarding oxygen administration and pain management deficiencies for Resident #55. |
| Certified Nurse Aide #3 | CNA | Observed failing to perform hand hygiene and disinfect equipment between resident care tasks. |
| Receptionist (RCT) | Receptionist | Observed conducting COVID-19 rapid testing without proper PPE and infection control. |
| Assistant Director of Nursing | ADON | Interviewed regarding infection control, oxygen administration, and medication management deficiencies. |
| Director of Nursing | DON | Interviewed regarding infection control, medication management, and COVID-19 testing procedures. |
| Dietary Manager | DM | Interviewed regarding menu deviations and pureed diet substitutions. |
| Registered Dietitian | RD | Interviewed regarding menu compliance and nutritional adequacy. |
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