Cappella of Pueblo West

A relicensure survey with complaint #CO40757 was completed on 2/25/26. A deficiency was cited. Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting two of four sample residents whose medications were reviewed (#2 and #6).Findings Include:1. Record reviewResident #6 was admitted to the residence on 5/8/23, with diagnoses including depressive disorder.A signed practitioner' s order, dated 9/11/25, directed the residence to administer one tablet Lybalvi 15/10 mg once daily. The January 2026 and February 2026 MAR read as follows:The January 2026 MAR read Resident #6 was not administered Lybalvi oral tablet for 31 days in January 2026, due to "medication unavailable."The February 2026 MAR read in part: Resident #6 was not administered Lybalvi oral tablet for 23 days in February 2026, due to "medication unavailable."2. InterviewsOn 2/25/26 at 7:50 a.m., Staff #4 stated Resident #6 had never been administered the medication because it was not covered by her insurance. Staff #4 said she called the resident' s practitioner on 10/6 and again on 10/7/25 to let the practitioner know that the medication was not covered by Resident #6' s insurance. She said the practitioner had told her that she was going to see Resident #6 on 10/7/25 and would write an order to discontinue the medication Lybalvi. Staff #4 said the order to discontinue was never written or received. On 2/25/26 at 9:10 a.m., the administrator said there was no order to discontinue Resident #6' s medication Lybalvi. The administrator said she had spoken with the practitioner back in October 2025, and the practitioner told her that the medication had been discontinued. She said the practitioner told her that she had already faxed the discontinued order over and would fax the order again; however, the administrator said the order was never received. The administrator said she was responsible for updating the MARs from September 2025 until January 2026. From January 2026 until the day of the onsite investigation, the new wellness director took over and became responsible. ..

A recertification survey with complaint #CO40758 was completed on 2/25/26. A deficiency was cited. Based on record review and interviews, the facility (residence) failed to provide sufficient support to members (residents) in the use of medications, affecting two of four sample residents (#2 and #6).Findings Include:1. Record reviewResident #6 was admitted to the residence on 5/8/23, with diagnoses including depressive disorder.A signed practitioner' s order, dated 9/11/25, directed the residence to administer one tablet Lybalvi 15/10mg once daily. The January 2026 and February 2026 MAR read as follows:The January 2026 MAR read Resident #6 was not administered Lybalvi oral tablet for 31 days in January 2026, due to "medication unavailable."The February 2026 MAR read in part: Resident #6 was not administered Lybalvi oral tablet for 23 days in February 2026, due to "medication unavailable."2. InterviewsOn 2/25/26 at 7:50 a.m., Staff #4 stated Resident #6 had never been administered the medication because it was not covered by her insurance. Staff #4 said she called the resident' s practitioner on 10/6 and again on 10/7/25 to let the practitioner know that the medication was not covered by Resident #6' s insurance. She said the practitioner had told her that she was going to see Resident #6 on 10/7/25 and would write an order to discontinue the medication Lybalvi. Staff #4 said the order to discontinue was never written or received. On 2/25/26 at 9:10 a.m., the administrator said there was no order to discontinue Resident #6' s medication Lybalvi. The administrator said she had spoken with the practitioner back in October 2025, and the practitioner told her that the medication had been discontinued. She said the practitioner told her that she had already faxed the discontinued order over and would fax the order again; however, the administrator said the order was never received. The administrator said she was responsible for updating the MARs from September 2025 until January 2026. From January 2026 until the day of the onsite investigation, the new wellness director took over and became responsible. The admi..