Pueblo Heights Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Pueblo Heights Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF740Apr 14, 2026

  Based on record review, observations and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (#1) of three residents reviewed for psychosocial well-being out of seven sample residents.Resident #1 was admitted to the facility on [DATE] with a history of attempted suicide by two self-inflicted gun shots to her head in 2025.When the resident admitted to the facility on [DATE], the hospital discharge orders included a physician's order for suicide precautions at the facility. However, record review revealed the facility failed to implement suicide precautions for Resident #1 and failed to implement a suicidal ideation care plan upon her admission. […]

• Actual harm, isolatedF689Jul 7, 2022

  Based on observations, record review and interviews, the facility failed to ensure three (#4, #3, and #6) of four residents reviewed for accidents out of six sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to develop and implement a person-centered care plan that identified Resident #4's fall risk and put effective interventions into place to reduce falls and prevent an injury. Resident #4 was admitted to the facility for long term care on 2/15/22 with a diagnosis of Lennox-gastaut syndrome ([CONDITION(S)]), diabetes mellitus type two, gastro-[CONDITION(S)] reflux disease (GERD), and chronic pain syndrome. On 2/16/22, one day after the resident's admission to the facility, the resident sustained a fall. […]

• Actual harm, isolatedF692Jul 7, 2022

  Based on observations, record review and interviews, the facility failed to ensure two (#4 and #3) of three out of six sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to adequately monitor residents nutritional status and put effective interventions in place to prevent significant weight loss. Resident #4 was admitted to the facility for long term care on 2/15/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When the resident was admitted to the facility he weighed 122 pounds (lbs). The facility failed to adequately monitor Resident #4's nutritional status by implementing effective nutrition interventions to prevent significant weight loss. […]

• No harm, potential for more than minimal, widespreadF921Jul 18, 2024

  Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident rooms, bathrooms and hallways received necessary maintenance repairs. Findings include: I. Observations and resident interviews Observations throughout the survey were conducted on 7/15, 7/16, 7/17 and 7/18/24 and revealed the following: A. Individual resident rooms room [ROOM NUMBER] had a leaking toilet and the tile on the bathroom floor on the corner edge under the sink was coming off the floor. The bathroom smelled like urine and mildew. The towel rack in the bathroom was not labeled. […]

• No harm, potential for more than minimal, widespreadF812Feb 16, 2023

  Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Cutting boards were free from deep scratches and stains. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.46-47, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: -Before handling or putting on single use gloves for working with food,… […]