Pueblo Heights Nursing and Rehabilitation

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (#1) of three residents reviewed for psychosocial well-being out of seven sample residents. Resident #1 was admitted to the facility on [DATE] with a history of attempted suicide by two self-inflicted gun shots to her head in 2025. When the resident admitted to the facility on [DATE], the hospital discharge orders included a physician's order for suicide precautions at the facility. However, record review revealed the facility failed to implement suicide precautions for Resident #1 and failed to implement a suicidal ideation care plan upon her admission. [...]

Inspectors wroteBased 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 and hallways received necessary maintenance repairs.

Inspectors wroteBased 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 three errors out of 31 opportunities for error.

Inspectors wroteBased 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. Specifically, the facility failed to ensure the resident's food was palatable in taste, texture and temperature.

Inspectors wroteBased 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 failed to: -Ensure enhanced barrier precautions (EBP) were implemented and followed for residents with wounds and/or indwelling medical devices; -Ensure residents' laundry was appropriately covered during transportation; and, -Ensure housekeeping used the proper cleaning method to sanitize a residents' rooms.

Inspectors wroteBased 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 ensure Resident #25 was provided with incontinence supplies.

Inspectors wroteBased 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 facility failed to ensure Resident #5 was assessed for safe self-administration of medications.

Inspectors wroteBased 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 reviewed out of 46 sample residents. Specifically, the facility failed to ensure Resident #289's bathroom call light was consistently accessible to him.

Inspectors wroteBased 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 abuse by Resident #65.

Inspectors wroteBased 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 services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #13 received assistance with ADLs, in the areas of dressing, personal hygiene and eating, in accordance with her comprehensive care plan.

Inspectors wroteBased 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 failed to regularly provide individualized, purposeful and therapeutic activities for Resident #62, who was a dependent resident.

Inspectors wroteBased 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 practice to prevent pressure injuries. Specifically, the facility failed to implement timely interventions to prevent Resident #84 from developing a Stage 2 pressure injury to his coccyx.

Inspectors wroteBased 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 pen was primed prior to medication administration for Resident #290.

Inspectors wroteBased 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 storage rooms. Specifically, the facility failed to: -Ensure a vial of Tubersol (used to test for tuberculosis) was discarded 30 days after it was opened; and, -Ensure expired medications were removed from the medication cart.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Cutting boards were free from deep scratches and stains.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 18 of 61 resident rooms in four hallways. Specifically, the facility failed to ensure walls, baseboard coves, halls, floors, doors, and floor tiles were repaired, painted and properly maintained.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards in one of four medication carts and one of two medication storage rooms. Specifically, the facility: -Failed to discard an expired vial of tuberculin; -Failed to date two vials of Levemir insulin when opened; -Failed to date a vial of glargine insulin (Lantus) when opened; -Failed to discard an expired vial of Humalog insulin; -Failed to date a vial of Novolog when opened; -Failed to date an Incruse and Trelegy inhaler when opened; -Failed to date an Advair inhaler when opened; and, -Failed to discard loose pills in the medication cart.

Inspectors wroteBased on interviews and record review, the facility failed to conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests for five (#44, #12, #69, #20 and #22) of five residents reviewed out of 29 sample residents. Specifically, the facility failed to document in the resident records the results of COVID-19 tests for Residents #44, #12, #69, #20 and #22.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#47 and #70) of three sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to assess Resident #47 and Resident #70 after a change of condition.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#68 and #15) out of 29 sample residents' environment remained free of accident hazards and the resident received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure timely assessment for use of wander guard for Resident #68; -Ensure the wander guard (elopement device) was monitored appropriately for Resident #68; and, -Implement effective fall interventions for Resident #15.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for two (#10 and #69) of five residents reviewed for vaccinations out of 29 sample residents. Specifically, the facility failed to ensure Residents #10 and #69 were offered and/or received pneumococcal immunization.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in two of four medication carts and one of two medication storage rooms. Specifically, the facility: -Failed to date insulins when opened; -Failed to identify whom an open vial of insulin belonged to; -Failed to discard expired nitroglycerin sublingual tablets; -Failed to date tuberculin when opened; and, -Failed to date an inhaler when opened.

Inspectors wroteBased on record review and interviews, the facility failed to honor resident choices for two (#65 and #11) of three reviewed for self-determination, out of 35 sample residents. Specifically, the facility failed to ensure Resident #65 and Resident #11 received showers consistently according to her choice and frequency.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#18) of three residents reviewed for oxygen therapy out of 35 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Resident #18.

Inspectors wroteBased on record review and interviews the facility failed to provide psychosocial support for one (#11) of three out of 35 sample residents. Specifically, the facility failed to: -Address and train staff on behaviors; and, -Develop a behavior plan to reduce behaviors related to incontinence for Resident #11.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#28) of five residents reviewed for unnecessary medications of 35 sample residents was free from unnecessary drugs. Specifically, the facility: -Failed to have an as needed (PRN) antipsychotic reviewed every 14 days for appropriateness of the medication by the physician or prescribing practitioner; and, -Failed to have an individualized person centered care plan addressing non-pharmacological interventions for the use of an antipsychotic PRN.