Pueblo Heights Nursing and Rehabilitation

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Egress Deficiencies

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

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Nutrition and Dietary Deficiencies

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

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

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

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 activities to meet all resident's needs.

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

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.

Nutrition and Dietary Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install properly constructed windows in hallway walls or doors.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

Perform COVID19 testing on residents and staff.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

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

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.

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.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Smoke Deficiencies

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

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

STANDARD is not met as evidenced by the: It was determined by record review and staff interview during the survey the facility failed to perform and document the exercising of all fire and smoke dampers at least every four years, per NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance. This deficient practice could affect all residents, staff, and visitors if the smoke dampers malfunction due to improper maintenance should a fire occur. Records were unavailable at the time of the survey to document the inspection and testing operation of the fire dampers installed in the facility as required every four years.NFPA 90A, Chapter 3, Section 3-4.7 Maintenance. At least every 4 years, fusible links (where applic.. STANDARD is not met: Through observation and discussion during the facility tour, it was determined that the facility failed to install and maintain the kitchen-hood-exhaust system as required by NFPA 96 (Chapter 7, Section 7.8.2). This deficient practice could affect all residents and staff should a fire occur due to failure to operate effectively due to non-code-compliant inspections and servicing. The up-blast fan on the kitchen hood exhaust system is not equipped with a hinged and flexible cable system to access for inspection and cleaning.NFPA 96 2011 section 7.8.2.1 Rooftop terminations shall be arranged with or provided with the following: (8) Hinged-up blast fan supplied with flexible weatherproof electrical cable and service hold-open retainer to permit inspection and cleaning that is listed .. STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff, and visitors should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance. A leaking pendent sprinkler head has been identified within the walk-in cooler.NFPA 101 2012 Edition Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating conditions and are installed, inspected, and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5The Director of Maintenance acknowledged the deficienc.. The Colorado Department of Fire Prevention and Control conducted this survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The Initial comments, (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.The facility is one story wood framed Type V (111), construction with a partial basement used for support services only. The basement has an exterior exit to grade level. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1955 and is license for 120 beds. This re-certification survey conducted on July 30, 2024 was for compliance with the National Fire Protection As.. The STANDARD was not met regarding the emergency lighting based on observation and staff interviews. The facility failed to maintain the battery-powered emergency lights per 7.9.3 and 19.2.9.1. This deficiency could affect all residents and staff throughout the facility during a primary power loss. No documentation was available during the record review of the facility-required testing of the battery-powered emergency lighting system annually for not less than 1 ½ hours. 2012 Life Safety Code 101-7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for ..

A recertification survey with complaint #CO36536 was completed on 7/15/24 to 7/18/24. Thirteen deficiencies were cited. An Emergency Preparedness survey was conducted from 7/15/24 to 7/18/24. No deficiencies were cited. Based on observation, record review and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections on two of four hallways. Specifically, the facility f.. Based on observation, record review and interviews, the facility failed to provide an ongoing program of activities for one (#62) of one resident reviewed for activity participation out of 46 sample residents.Specifically, the facility faile.. Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in one of four medication carts and one of two medication sto.. 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 a.. Based on observations, record review and interviews, the facility failed to ensure one (#13) of one resident reviewed for assistance with activities of daily living (ADL) out of 46 sample residents received appropriate treatment and serv.. Based on observations, record review and interviews, the facility failed to ensure one (#84) of three residents reviewed for pressure injuries out of 46 sample residents received care consistent with professional standards of prac.. Based on observations, record review and interviews, the facility failed to ensure one (#290) of nine residents out of 46 sample residents were free from significant medication errors.Specifically, the facility failed to ensure the insulin .. Based on observations, record review and interviews, the facility failed to ensure resident rights were promoted and dignity was maintained for one (#25) of two residents out of 46 sample residents.Specifically, the facility failed to en.. Based on observations, record review and interviews, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value and were palatable in taste, texture and temperature.Specificall.. Based on observations, record review and interviews, the facility failed to ensure the self-administration of medication was clinically appropriate for one (#5) of one resident out of 46 sample residents. Specifically, the facilit.. Based on observations, record review and interviews, the facility failed to provide reasonable accommodation necessary to accommodate mobility and accessibility in the resident' s environment for one (#289) of one resident rev.. Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater.Specifically, the medication administration observation error rate was 9.68%, or th.. Based on record review and interviews, the facility failed to take steps to prevent abuse for one (#23) of two residents reviewed for abuse out of 46 sample residents.Specifically, the facility failed to protect Resident #23 from sexual ab..