Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Center At Park West Llc, The during CMS and state inspections, most recent first.
Two residents did not receive timely and appropriate wound care or documentation: one with a recent amputation did not have her surgical site consistently monitored or antibiotics started promptly after infection was identified, resulting in hospitalization, while another admitted with a skin tear experienced delays in obtaining wound care orders and proper documentation. Staff interviews confirmed lapses in communication and adherence to wound care protocols.
Two residents did not receive necessary treatment and services to prevent or heal pressure injuries. One resident developed a pressure ulcer that was not accurately identified or documented, and timely interventions such as an air mattress were delayed. Another resident with a Stage 4 pressure ulcer did not have consistent documentation or monitoring of wound care, repositioning, or pressure-relieving equipment, and changes in skin condition were not communicated to the physician. These deficiencies resulted from incomplete assessments, poor documentation, and lack of timely intervention.
Three residents did not receive complete baseline care plans within 48 hours of admission, with omissions such as missing interventions for psychotropic and anticoagulant medications, incomplete dietary and discharge planning, and lack of documentation that residents or their representatives received or reviewed the care plans. Staff interviews confirmed inconsistent processes for care plan development and communication.
The facility failed to provide individualized, person-centered care and activities for three residents with dementia, resulting in unmet needs and lack of engagement. Staff did not implement or follow care plans that addressed residents' preferences, such as offering preferred activities or providing meaningful engagement, and residents were often left idle, unattended, or without appropriate interventions for their cognitive and behavioral symptoms.
A resident's representative filed a grievance regarding concerns that physical therapy was not following the prescribed weight-bearing orders. The facility failed to provide prompt and effective resolution, and the grievance documentation was incomplete, lacking required signatures and a clear indication of resolution or satisfaction.
Two residents dependent on staff for ADLs did not consistently receive needed assistance with bathing and meals. One resident with severe cognitive impairment was not regularly encouraged to eat or provided scheduled showers, with incomplete documentation of refusals. Another resident with quadriplegia and a stage 4 pressure ulcer reported not receiving bed baths for weeks, and records showed only two baths in a month, with no consistent documentation of refusals or alternative care approaches. Staff interviews confirmed gaps in care and documentation.
The facility failed to secure resident medical records by not ensuring nursing staff logged off workstations, leaving electronic medical records (EMRs) visible to non-staff. Observations showed unattended computers with open EMRs at nurses' stations and hallways, accessible to residents and visitors. Staff interviews confirmed awareness of the need to log off, but a formal policy was not provided.
A resident with multiple health issues experienced inadequate pain management due to the facility's failure to complete comprehensive pain assessments and offer non-pharmacological interventions. The resident preferred non-medication interventions, but the facility did not consistently provide or monitor these. Discrepancies in documentation and staff awareness further contributed to the deficiency.
A resident with fragile skin due to edema sustained a skin tear during a staff-assisted transfer when a CNA moved too quickly, causing the walker to hit her shin. The incident was not promptly investigated, and there was a delay in updating the care plan to prevent further injuries. Staff interviews revealed inconsistencies in understanding the resident's assistance needs and handling skin injuries.
A facility failed to ensure a resident was free from unnecessary medications by not documenting sleep hours or attempting person-centered interventions before administering antipsychotic medication. The resident, with severe cognitive impairments, frequently called for help, but staff did not consistently engage or provide meaningful activities. The care plan lacked documentation of specific delusions or effective interventions, and staff interviews revealed a lack of personalized care plans and monitoring.
A facility failed to initiate a hospice care plan for a resident admitted to hospice services for metabolic encephalopathy. Despite facility policy requiring a comprehensive care plan, there was no plan indicating the division of responsibilities between the facility and hospice services. Staff interviews revealed a lack of awareness and communication regarding the care plan, with the DON and MDSC unaware of the oversight. The MDSC admitted that although a change of condition was updated, the care plan was never initiated.
The facility did not ensure that CNAs received annual training in dementia management and abuse prevention. Three CNAs had not completed the required training, and the facility lacked documentation and a formal training policy. The DON could not provide evidence of recent training sessions.
Failure to Provide Timely Wound Care and Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents. For one resident with a recent left below-the-knee amputation, the facility did not provide timely, consistent, and effective monitoring or appropriate documentation of the surgical incision. Although the initial skin assessment documented the incision as well approximated, subsequent wound care assessments failed to address the amputation site. When the resident and physician identified signs of infection, antibiotics were ordered, but there was a delay of two days before these medications were entered into the electronic medical record and administered. Throughout this period, nursing documentation did not consistently reflect monitoring of the incision for signs of worsening infection, despite the resident being on antibiotics. The resident ultimately required hospitalization for an infected amputation site, where she underwent further surgical intervention and did not return to the facility. Additionally, the facility failed to obtain timely wound care orders for another resident admitted with a skin tear to the left lower leg. Upon admission, the nursing note documented a single wound, but did not address a larger skin tear observed later. The admitting nurse did not change the dressing, citing the absence of wound care orders, and the wound care nurse delayed entering the necessary orders into the electronic medical record. As a result, the resident did not receive appropriate wound care or documentation for two days after admission, and the wound care provided was not properly documented. Staff interviews confirmed lapses in communication and documentation. The wound care nurse stated she was not notified of changes to the amputation site and did not follow wounds unless issues were reported. The director of nursing and other nursing staff described expectations for wound monitoring and documentation that were not met in these cases. The deficiencies were directly related to failures in timely assessment, documentation, and implementation of physician orders for wound care and infection management.
Failure to Prevent and Manage Pressure Ulcers Due to Inadequate Assessment and Intervention
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and heal pressure injuries for two residents. For one resident, who was at risk for skin breakdown due to multiple comorbidities including a recent hip fracture, diabetes, chronic kidney disease, and impaired mobility, the facility did not accurately identify, document, evaluate, or monitor a developing pressure ulcer. The skin breakdown was initially documented as moisture-associated skin damage (MASD) and later as an abrasion, but the area was not recognized or treated as a pressure injury. Weekly skin assessments were inconsistent and incomplete, failing to identify the wound's progression, and the care plan did not include timely interventions such as an air mattress until after the wound had developed. Upon discharge, the resident was found by the receiving facility to have an open wound with slough, which was later identified as a Stage 4 pressure ulcer with exposed bone. For another resident with quadriplegia and a known Stage 4 pressure ulcer, the facility did not ensure consistent implementation and documentation of wound prevention and care interventions. Observations revealed that the resident's air mattress and wound vac settings were not consistently monitored or documented, and there were lapses in the application of barrier cream and repositioning. The care plan and treatment administration records showed missing documentation for multiple wound care and prevention interventions, and the physician was not notified of changes in the resident's skin condition, including the development of MASD and maceration around the wound. Staff interviews confirmed that wound care was not always measured or documented as required, and that the function and settings of pressure-relieving devices were not routinely checked or recorded. Both cases demonstrated a lack of thorough and accurate assessment, documentation, and timely intervention for pressure injuries. The facility did not follow its own policies for skin evaluation, risk assessment, and physician notification when new or worsening skin conditions were identified. These failures resulted in unaddressed and undocumented pressure injuries, incomplete care plans, and inadequate monitoring of wound care interventions and pressure-relieving equipment.
Failure to Develop and Communicate Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive baseline care plans within 48 hours of admission for three residents, as required by its own policy and federal regulations. For one resident with Alzheimer's disease, a femur fracture, and other complex conditions, the baseline care plan omitted necessary details such as interventions for psychotropic and anticoagulant medications, did not specify the required mechanical soft diet, and lacked complete discharge planning information. Additionally, there was no documentation that the resident or their representative received or reviewed the baseline care plan, and the social services director did not meet with the resident until three days post-admission, without reviewing the care plan during that meeting. Another resident, admitted after a coronary artery bypass graft and left toe amputation, had a baseline care plan that addressed the amputation but failed to include the surgical wound from the bypass procedure. This resident also reported not receiving or reviewing a copy of the baseline care plan, and there was no documentation of a signed acknowledgement form in the medical record. Similarly, a third resident with severe cognitive impairment and prescribed antipsychotic medication had a baseline care plan that did not specify the use of antipsychotic medication or include appropriate interventions, and there was no evidence that the responsible party received the care plan. Staff interviews revealed inconsistencies in the process for developing, reviewing, and obtaining signatures for baseline care plans. The admitting nurse was identified as responsible for these tasks, but documentation was lacking in all three cases. The facility's failure to provide timely, person-centered baseline care plans and to ensure residents or their representatives were informed contributed directly to the deficiency.
Failure to Provide Person-Centered Dementia Care and Activities
Penalty
Summary
The facility failed to provide appropriate, person-centered treatment and services to residents diagnosed with dementia, as evidenced by observations, record reviews, and staff interviews involving three residents. For one resident with mild neurocognitive disorder and behavioral disturbances, staff did not offer preferred activities listed in the care plan, such as arts and crafts, games, or outdoor activities. Instead, the resident was observed sitting idly at the nurse's station or wandering into other residents' rooms without effective person-centered interventions to prevent such behavior. Staff interviews revealed a lack of awareness regarding individualized dementia care planning, and interventions were limited to redirection or providing generic items like a busy board or Rubik's cube, which were not effective or tailored to the resident's preferences. Another resident with severe cognitive impairment and dementia was observed repeatedly calling for help without timely staff response and was left with a television playing in a language she did not understand for over an hour. The care plan indicated she enjoyed music, social events, and being outdoors, but these preferences were not addressed during the observed periods. Staff did not provide or encourage participation in meaningful activities, and the resident was often left idle or unattended, contrary to her documented needs and preferences. A third resident with severe cognitive impairment, behavioral disturbances, and a history of wandering was not provided with any person-centered activities during multiple observation periods. The care plan included general interventions such as redirection and monitoring, but lacked individualized approaches to address his dementia care needs. Staff interviews confirmed difficulties in engaging the resident in activities and a lack of Spanish-speaking activities, despite the resident's language abilities. The resident was also observed to be combative and was moved for safety reasons, but no specific, person-centered interventions were documented or implemented to address his behavioral and cognitive needs.
Failure to Promptly Resolve and Document Resident Grievance
Penalty
Summary
The facility failed to ensure prompt and effective resolution of a grievance filed by a resident's representative regarding the resident's physical therapy and weight-bearing status. The representative expressed concerns that the weight-bearing orders from the orthopedic surgeon were not being followed and reported dissatisfaction with the explanations provided by the director of rehabilitation. Despite attempts to communicate these concerns, including an email to the nursing home administrator, the representative did not receive a satisfactory response or resolution. A review of the grievance documentation revealed that the grievance form was incomplete, lacking required signatures, substantiation status, and a clear indication of resolution or satisfaction. The form noted the representative's continued concerns and hesitancy regarding the outcome. Staff interviews confirmed that the facility's grievance process was not properly followed, as there was no documentation of when the grievance was resolved or whether the resolution met the representative's satisfaction. The facility's policy required thorough documentation and timely resolution, which was not demonstrated in this case.
Failure to Provide Necessary ADL Assistance and Documentation
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, with diagnoses including cellulitis, lymphedema, and benign prostatic hyperplasia, was assessed as having severely impaired cognition and was dependent on staff for bathing, dressing, and personal hygiene, and required supervision or assistance with eating. Observations revealed that staff did not consistently encourage or assist the resident to eat more when he consumed only a small portion of his meals, and there were gaps in bathing documentation, with no evidence of refusals during a nine-day period when no showers were provided. Another resident, diagnosed with multiple sclerosis, quadriplegia, and a stage 4 pressure ulcer, was completely dependent on staff for all ADLs. This resident reported not having received a bed bath in several weeks, and observations confirmed poor hygiene and an unpleasant odor in the room. The care plan indicated a preference for bed baths twice weekly, but records showed only two baths documented in a four-week period, with no consistent documentation of refusals or alternative approaches. Staff interviews confirmed a lack of awareness of refusals and inconsistent documentation practices. In both cases, the facility did not ensure that residents who were unable to carry out ADLs received the necessary services to maintain personal hygiene and good nutrition. Documentation was incomplete or missing regarding refusals and care provided, and staff did not consistently follow up or encourage residents to participate in their care as required by their care plans.
Failure to Secure Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical records by not ensuring that nursing staff logged off their workstations when leaving the area. Observations on the second and third floors revealed multiple instances where computers with open electronic medical records (EMRs) were left unattended. These computers were located at nurses' stations, hallway workstations, and on medication carts, making the information visible to residents, visitors, and family members passing by. Specific incidents included an unidentified nurse and certified nurse aide (CNA) leaving their screens open, as well as a licensed practical nurse (LPN) repeatedly leaving her computer screen open at the nurses' station. Interviews with staff, including CNAs and LPNs, confirmed that they were aware of the requirement to log off workstations to protect resident information. The nursing home administrator (NHA) also acknowledged the importance of not leaving monitors unattended to maintain privacy. Despite this awareness, the facility did not provide a protected health information policy when requested, indicating a lack of formalized procedures to ensure compliance with confidentiality standards.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide an effective pain management regimen for a resident, identified as Resident #32, who was admitted with multiple diagnoses including type 2 diabetes, interstitial pulmonary disease, heart failure, atrial fibrillation, morbid obesity, and unsteadiness on her feet. The resident was cognitively intact and required assistance with daily activities. Despite frequently experiencing moderate pain that affected her sleep and daily activities, the facility did not complete a comprehensive pain assessment that identified the type of pain, its effects on the resident, aggravating and relieving factors, and associated symptoms. The facility also failed to offer and monitor person-centered non-pharmacological interventions for pain management. The resident expressed a preference for non-pharmacological interventions over pain medications, yet the facility did not provide such interventions consistently. The care plan did not specify the location of the resident's pain, and the electronic medical record lacked documentation on the effectiveness of non-pharmacological interventions. Additionally, there was a discrepancy between the nursing progress notes and the medication administration record regarding the administration of pain medications. Interviews with staff revealed inconsistencies in the pain management process. Certified nurse aides and nurses were not fully aware of the resident's pain management plan, and the director of nursing was unaware of the inaccuracies in the pain assessments and documentation. The facility did not update the resident's electronic medical record to reflect effective interventions or to monitor the effectiveness of non-pharmacological interventions, contributing to the deficiency in providing appropriate pain management for the resident.
Failure to Prevent Skin Tear During Transfer
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for Resident #32, who sustained a skin tear during a staff-assisted transfer. Resident #32, an 83-year-old with multiple health conditions including type 2 diabetes and morbid obesity, required substantial assistance for daily activities. On the day of the incident, the resident reported that a CNA moved too quickly during toileting care, causing the walker to hit her shin and result in a skin tear. The resident expressed concern about her fragile skin due to edema and the need for careful handling. The incident was not thoroughly investigated at the time it occurred. The day shift nurse did not document the specifics of the skin tear, such as how it happened, the skin assessment, or any pain assessment. There was also a lack of immediate care plan updates to prevent further skin tears. The facility's documentation revealed that the skin tear was not addressed with new interventions until several days later, during the survey. The CNA involved did not report the incident to the nurse immediately, and the nurse on duty did not notify the physician or obtain wound care orders promptly. Interviews with staff, including CNAs and nurses, highlighted inconsistencies in the understanding of the resident's assistance needs and the protocol for handling skin injuries. The DON acknowledged that the incident was not investigated until days later, as the nurse responsible was on vacation. The facility's failure to conduct a timely investigation and implement preventive measures contributed to the deficiency in providing a safe environment for Resident #32.
Failure to Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically in the case of a 77-year-old resident with severe cognitive impairments and multiple diagnoses, including dementia and mood disturbances. The resident was observed repeatedly asking for help, but staff did not consistently engage with him to determine his needs or provide meaningful activities. Instead, the resident was administered psychotropic medication without documented attempts of non-pharmacological interventions or monitoring of sleep hours, which are necessary to justify the use of such medications. Observations revealed that the resident frequently called out for help, yet staff members, including CNAs and nurses, often did not respond or provide assistance. The care plan for the resident's antipsychotic medication lacked documentation of specific delusions or effective non-pharmacological interventions. Additionally, there was no care plan to monitor the resident's sleep hours, despite the use of Melatonin for insomnia. The facility's failure to document and implement person-centered interventions before resorting to antipsychotic medication contributed to the deficiency. Interviews with staff, including LPNs and the DON, highlighted a lack of personalized interventions and monitoring for the resident. The DON acknowledged the importance of personalized care plans and monitoring sleep when residents are on hypnotic or antipsychotic medications. However, the facility did not have a system in place to ensure these practices were followed, leading to the resident receiving unnecessary medication without adequate justification or alternative interventions being attempted.
Failure to Initiate Hospice Care Plan for Resident
Penalty
Summary
The facility failed to ensure a hospice care plan was initiated for Resident #19, who was admitted to hospice services for metabolic encephalopathy. Despite the facility's policy requiring a comprehensive, person-centered care plan for each resident, there was no care plan indicating the division of responsibilities between the facility and hospice services for Resident #19. This oversight was identified during a review of the resident's records, which showed that although hospice services were ordered, the care plan did not reflect this change. Interviews with facility staff revealed a lack of awareness and communication regarding the implementation of the hospice care plan for Resident #19. Certified Nurse Aide (CNA) #2 and Registered Nurse (RN) #2 both acknowledged that a care plan should be in place for residents receiving hospice care. However, RN #2 admitted to not knowing the resident's goals for end-of-life care and was unaware that a care plan had not been initiated. The Director of Nursing (DON) also confirmed that a hospice care plan should have been implemented but was not aware of the oversight. The Minimum Data Set Coordinator (MDSC) was responsible for implementing comprehensive care plans and stated that the care plans should be updated daily. However, the MDSC was not aware that a hospice care plan had not been initiated for Resident #19. The MDSC mentioned that a change of condition was updated in the MDS assessment, but the care plan was never initiated, indicating a lapse in the facility's process for updating and implementing care plans for residents receiving hospice services.
Failure to Provide Required Training for CNAs
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required annual training in dementia management and abuse prevention. Specifically, CNAs #3, #4, and #5 did not complete the necessary training. A review of the training records revealed that CNA #5 had not received dementia and abuse training since May 2023, CNA #4 since June 2023, and CNA #3 since July 2023. The Director of Nursing (DON) was unable to provide documentation or an agenda for recent abuse training conducted by the nursing home administrator, who also served as the abuse coordinator. Additionally, the facility lacked a formal training policy or procedure for dementia and abuse, and the sign-in sheet for a dementia training session held in May 2024 did not include signatures from the three CNAs in question.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pueblo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| High Plains Post Acute Llc | 3.1 mi | ★★★★★ | 6 | 0 |
| Vista Ridge Care And Rehabilitation | 3.6 mi | ★★★★★ | 20 | 1 |
| University Park Care Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Pueblo Heights Nursing And Rehabilitation | 4.6 mi | ★★★★★ | 1 | 1 |
| Rock Canyon Respiratory And Rehabilitation Center | 5.1 mi | ★★★★★ | 1 | 0 |
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