Pueblo Springs Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Pueblo Springs Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 13, 2023

  Based on clinical record review, staff interviews, facility documents and policy, the facility failed to ensure that 2 residents (#32 and #78) are not abused by staff. The deficient practice could result in staff abuse of residents. Findings include: -Resident #32 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis, major depressive disorder and anxiety disorder. An Annual Minimum Data Set (MDS) dated [DATE] included that this resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. […]

• No harm, potential for more than minimal, patternF600Jun 6, 2025

  Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#284) was free from physical abuse from other residents (resident #15). The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #284 was admitted to the facility on [DATE], with diagnosis that include quadriplegia, urinary tract infections, diabetes mellitus type 2, weakness, hypertension, pressure ulcers, spinal stenosis, anxiety, insomnia, and myocardial infarction. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF812Jun 6, 2025

  Based on observations, staff interviews and review of policies and procedures, the facility failed to ensure that food was labeled, stored and plated in accordance with professional standards, and that personal items were not located on food preparation counters. The deficient practices could result in food-borne illnesses. Findings include: An initial kitchen observation was conducted on June 3, 2025 at 09:51 A.M. in conjunction with the dietary manager, (Staff #28). The lead cook, (Staff #71) was also present. During observation of the food preparation area, non-food personal items including two portable speakers were located on the food preparation areas. […]

• No harm, potential for more than minimal, patternF842Jun 6, 2025

  Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure that medical record were complete and accurate for four residents (#27, #16, #14, and #30). The deficient practice could lead to care team members not being aware of a resident's status, and could lead to missed or services rendered. Findings include: -Regarding Resident #27 Resident #27 was admitted [DATE] with diagnosis including hemiplegia and hemiparesis affecting right dominant side, dysarthria, end stage renal disease, moderate protein calorie malnutrition, hypertension, major depressive disorder-recurrent, anemia, insomnia, gastro-esophageal reflux and dependence on renal dialysis. […]

• No harm, potential for more than minimal, patternF880Jun 6, 2025

  Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure that staff follows appropriate infection control practices. The deficient practice could result in a spread of preventable illness to residents and staff. Findings included: Resident #56 was admitted to the facility on [DATE] with the diagnosis of quadriplegia, unspecified. A care plan focus initiated on October 14, 2024 revealed that the resident has a suprapubic catheter and that staff is to use enhanced barrier precautions when providing services. Another care plan focus initiated on October 14, 2024 revealed that the resident has a diabetic ulcer and that staff is to use enhanced barrier precautions when providing services. […]