Pavilion at Villa Pueblo, the

Construction Deficiencies

Use approved construction type or materials.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

A complaint survey, prompted by #CO39825, #CO39886, #CO39914, #CO39964, Incident #39815 and Incident #39827 was completed on 5/12/25 to 5/15/25. Four deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure one (#1) of four residents reviewed for abuse out of seven sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #1 from sexual abuse by Resident #6.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation Prevention policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 5/12/25 at 10:30 a.m. It read it pertinent part,"Our facility prohibits the abuse, mistreatment, neglect, and/or exploitation of residents. We believe that all residents have the right to be free from such actions by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving our community, family members or legal guardians, friends, or any other individuals. "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or me.. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#2) of three residents reviewed for ADLs out of seven sample residents. Specifically, the facility failed to ensure Resident #2, who was dependent on staff for care, received showers per her preference. Findings include:I. Facility policy and procedureThe Bath Shower/Tub policy and procedure, revised January 2025, was received from the nursing home administrator (NHA) on 5/14/25 at 11:08 a.m. It revealed in pertinent part, "The purpose of this procedure is to promote cleanliness, provide comfort to the resident and observe the condition of the resident' s skin."Document the date and time the shower/tub bath was performed, and the name and title of the individual who is assigning the resident with the shower/tub bath, all assessment data (any reddened areas, sores on the residents skin) obtained d.. Based on observations, record review, and interviews, the facility failed to ensure two (#2 and #4) of seven residents out of seven sample residents received services provided or arranged by the facility that met professional standards of quality. Specifically, the facility failed to ensure weekly skin assessments were consistently completed, per physican' s orders, for Resident #2 and Resident #4.Findings include:I. Facility policy and procedureThe Professional Standards policy, revised December 2024, was provided by the nursing home administrator (NHA) on 5/15/25 at 8:43 a.m. It read in pertinent part,"The facility is committed to providing the highest quality of care to our residents. We believe that everyone deserves to live with dignity, respect, and the opportunity to thrive. Our goal is to foster a safe, nurturing, and supportive environment through continuous improvement in care practices."Communication and coordination of care: effective communication among all members of the care team, residents, and families will be prioritized to en..