Pueblo Springs Rehabilitation Center

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

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

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.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Resident Rights Deficiencies

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

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

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.

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.

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 safe and appropriate respiratory care for a resident when needed.

Resident Assessment and Care Planning Deficiencies

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

Nutrition and Dietary Deficiencies

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

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.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater." (1.) NFPA 13, Standard for the Installation of Sprinkler Systems" NFPA 13, Section 8.15.7 Exterior roofs, Canopies, Porte-Cochers, Balconies, Decks or Similar Projections. Section 8.15.7.1 Unless the requirements of 8.15.7.2,8.15.7.3 , or 8.15.7.4 are met sprinklers shall be installed under exterior roofs, canopies, Porte-cocheres, balconies, decks, or similar projections exceeding 4 ft in width. Findings include: Observations made while on tour on June 10, 2025, revealed that the roof overhang at the entrance on the south side of the facility, as well as one on the west side of the facility, were not sprinklered. The doors in these locations are recessed, and the distance from the door to the edge of the roof line is approximately 68 inches. The facility is constructed of Type V materials. All other entrances into the building are sprinklered. The management team acknowledged during the facility tour and exit conference on June 10, 2025, that the above-listed areas on the east and north sides of the facility were not sprinklered.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater." (1.) NFPA 13, Standard for the Installation of Sprinkler Systems" NFPA 13, Section 8.15.7 Exterior roofs, Canopies, Porte-Cochers, Balconies, Decks or Similar Projections. Section 8.15.7.1 Unless the requirements of 8.15.7.2,8.15.7.3 , or 8.15.7.4 are met sprinklers shall be installed under exterior roofs, canopies, Porte-cocheres, balconies, decks, or similar projections exceeding 4 ft in width. Findings include: Observations made while on tour on June 10, 2025, revealed that the roof overhang at the entrance on the south side of the facility, as well as one on the west side of the facility, were not sprinklered. The doors in these locations are recessed, and the distance from the door to the edge of the roof line is approximately 68 inches. The facility is constructed of Type V materials. All other entrances into the building are sprinklered. The management team acknowledged during the facility tour and exit conference on June 10, 2025, that the above-listed areas on the east and north sides of the facility were not sprinklered.