Below 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 High Plains Post Acute Llc during CMS and state inspections, most recent first.
Three residents with significant fall risks and cognitive impairments did not receive adequate supervision or consistent implementation of fall prevention interventions. One resident was left unattended on a commode and fell after waiting over 25 minutes for staff, resulting in serious injuries. Another resident experienced multiple unwitnessed falls due to inconsistent use of a prescribed tactile pillow, and a third was repeatedly transported in a wheelchair without foot pedals, requiring her to hold her feet up. Staff interviews and documentation confirmed lapses in following care plans and uncertainty about safety practices.
Residents were not given the opportunity or support to organize and participate in resident or family groups, as required by regulations.
Four residents with severe cognitive impairments and various medical conditions were not provided with ongoing, individualized activity programs that matched their documented preferences, such as music, pet visits, group activities, and outdoor time. Observations showed these residents were often left unengaged in common areas or their rooms, and staff did not offer or document the provision of preferred activities, despite care plans indicating their importance.
Nursing staff did not follow physician-ordered pain medication parameters for a resident with severe cognitive impairment, administering tramadol for moderate pain levels when acetaminophen was indicated. This was confirmed through record review and staff interviews, revealing a failure to adhere to the facility's pain management policy and the resident's care plan.
Two residents who required continuous oxygen therapy were found with empty portable oxygen tanks, and staff did not consistently use appropriate PPE when refilling the tanks. The care plans and monitoring practices did not ensure that oxygen was provided as ordered, and equipment malfunctions were not promptly addressed.
Residents reported ongoing hunger after meals, and observations revealed that portion sizes were small and not always consistent with the planned menu. Staff interviews confirmed a lack of clarity regarding portioning and menu adherence, and documentation showed that daily caloric intake sometimes fell below recommended levels, resulting in unmet nutritional needs.
A facility failed to prevent accidents for three residents, leading to fractures and falls. One resident with osteoporosis sustained multiple fractures without timely interventions or root cause analysis. Another high fall-risk resident experienced several unwitnessed falls, with inconsistent implementation of fall prevention measures and no new interventions after incidents. Additionally, the facility did not complete a root cause analysis for a skin tear incident. The facility's policy required documentation of incidents, but there was a lack of formal analysis and intervention implementation.
A resident with a chronic Foley catheter did not have a physician's order for catheter use and maintenance upon admission and readmission, and staff failed to document catheter care and urinary output as required. Although staff reported performing catheter care, there was no evidence of this in the EMR, TAR, or progress notes until new orders were entered during the survey. This resulted in a failure to provide care and services according to professional standards.
Staff failed to consistently follow Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter, as required by CDC guidance and facility policy. During high-contact care activities such as repositioning and linen changes, a staff member did not wear a gown, despite direct contact with the resident and their bedding, while other staff did use full PPE. Interviews revealed inconsistent understanding and application of EBP protocols among staff.
The facility did not effectively track or monitor long-term antibiotic use for two residents, as required by CDC guidelines and facility policy. One resident received ongoing nitrofurantoin without documented duration, diagnosis, or risk-benefit analysis, and was not included in infection surveillance. Another resident was on long-term ciprofloxacin without documentation of side effect monitoring, antibiotic checklist completion, or infection surveillance, and the IP was unaware of the antibiotic use. These deficiencies reflect a lack of adherence to antibiotic stewardship protocols.
A resident with advanced Huntington's disease, identified as a fall risk, was left unattended by a CNA who had raised the bed and removed the fall mat. The resident fell out of bed, sustained a head injury and a sacral fracture, and later passed away. The facility's investigation confirmed that the CNA failed to follow established safety protocols.
Failure to Prevent Accidents Due to Inadequate Supervision and Implementation of Fall Interventions
Penalty
Summary
The facility failed to ensure that three residents received adequate supervision and that their environment was free from accident hazards, resulting in preventable accidents. One resident, admitted with a history of a recent hip fracture due to a fall at home and severe cognitive impairment, was incorrectly assessed as low fall risk upon admission. Despite a care plan that included keeping items within reach and assisting with transfers, the resident was left unattended on a bedside commode for over 25 minutes after activating the call light. The resident attempted to retrieve toilet wipes that were not within reach, resulting in a fall that caused a right wrist and right hip fracture, requiring hospitalization. The interventions for supervision during toileting and the use of a reacher device were only implemented after the fall occurred. Another resident, with diagnoses including dementia, muscle weakness, and a history of falls, was identified as high risk for falls. Observations revealed that required fall prevention interventions, such as the use of a tactile wedge pillow to provide bed boundaries, were not consistently implemented. The resident experienced multiple unwitnessed falls, and staff interviews confirmed a lack of awareness and inconsistent use of the prescribed interventions. Documentation showed that the resident was found on the floor on more than one occasion without the tactile pillow in place, despite it being part of the care plan. A third resident, also with dementia and a history of frequent falls, was observed being transported in a wheelchair without foot pedals attached, requiring the resident to hold her legs and feet up off the ground. This occurred multiple times, and staff did not intervene to ensure the resident's safety during transport. The care plan did not include an intervention to ensure foot pedals were in place during staff-assisted transport, and staff interviews revealed uncertainty about best practices for wheelchair foot pedal use. These failures demonstrate that the facility did not consistently implement or communicate individualized fall prevention interventions as required by their own policies.
Failure to Support Resident/Family Group Participation
Penalty
Summary
The facility failed to honor the right of residents to organize and participate in resident and family groups. This deficiency was identified based on observations and interviews indicating that residents were not provided the opportunity or support to form or participate in such groups within the facility. There were no specific details provided about individual residents, their medical history, or their condition at the time of the deficiency.
Failure to Provide Individualized Activity Programs for Residents
Penalty
Summary
The facility failed to provide an ongoing, individualized program of activities designed to meet the needs and interests of four residents, as required. For one resident with severe cognitive impairment and a neurogenetic disorder, care plans indicated a preference for music, pet visits, group activities, and spiritual practices. However, participation logs and staff interviews confirmed that pet visits were not offered, and observations showed the resident was often left sitting or sleeping in common areas without engagement in preferred activities. Another resident with polyneuropathy and a history of stroke, also severely cognitively impaired, was observed repeatedly sitting in hallways and common areas without meaningful activity or staff interaction, despite a care plan indicating interests in group and individual activities, crafts, and pet visits. Staff passed by without engaging the resident, and there was no evidence that preferred activities were provided. A third resident with dementia and vision impairment was observed alone in her room or in her wheelchair without any engaging activities, and staff did not offer participation in scheduled group activities. The activity cart lacked materials suitable for her preferences, such as music or sensory items, and participation records did not show that musical activities were offered. A fourth resident with Alzheimer’s and severe cognitive impairment was observed isolated during activities and not engaged with the television, with care plans indicating a preference for outdoor activities and pet visits, which were not provided. Staff interviews and participation logs confirmed that these individualized activities were not offered, and the resident’s sensory mat was not utilized when she appeared restless.
Failure to Follow Physician-Ordered Pain Medication Parameters
Penalty
Summary
Nursing staff failed to administer pain medication according to physician-ordered parameters for one resident with severe cognitive impairment and multiple diagnoses, including dementia, anxiety, and a history of falls. The resident had physician orders specifying the use of acetaminophen for mild to moderate pain (pain scale 1-6) and tramadol for severe pain (pain scale 7-10). Despite these clear orders, the medication administration records showed that the resident was given tramadol for pain levels of 5 and 6 on multiple occasions, when acetaminophen should have been administered according to the orders. Interviews with nursing staff and review of the electronic medical record confirmed that tramadol was not administered in accordance with the physician's specified pain parameters. The DON and corporate nurse consultant acknowledged the discrepancy after reviewing the records. The facility's pain management policy required the use of appropriate pain assessment tools and collaboration with the interdisciplinary team to develop and implement individualized pain management interventions, but these standards were not followed in this case.
Failure to Ensure Continuous Oxygen Supply and Proper PPE Use
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required supplemental oxygen. In both cases, the residents' portable oxygen tanks were found to be empty during routine activities, despite physician orders for continuous oxygen therapy. One resident, who had diagnoses including COPD and chronic respiratory failure with hypoxia, was observed calling for assistance when she noticed her oxygen was not flowing, and staff confirmed her tank was empty. The care plan for this resident did not specify how often staff should check the oxygen tank to ensure it remained full. Another resident, with a history of COPD and other chronic conditions, was also found with an empty portable oxygen tank. Staff noted that the tank had been refilled earlier but suspected a malfunction due to abnormal behavior of the tank's dial, which may have contributed to the tank being empty prematurely. Additionally, the facility did not ensure that staff used the appropriate personal protective equipment (PPE) when filling portable oxygen tanks, as required by facility policy. The deficiency was identified through observations, record reviews, and staff interviews, which revealed lapses in monitoring oxygen tank levels and adherence to safety protocols for handling respiratory equipment. These failures resulted in residents not receiving oxygen as ordered and not being protected during the refilling process.
Failure to Provide Adequate Nutrition and Menu Adherence
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of residents, as required by policy and regulatory standards. Residents reported that meals did not satisfy their hunger and that they were left hungry after meals, with one resident unable to eat provided snacks due to dental issues. Review of menu extensions revealed that portion sizes were not always specified, and the total daily caloric intake on at least one day was below the recommended range set by the registered dietitian. Observations confirmed that portion sizes were small, and there were inconsistencies between the planned menu and what was actually served, such as serving a biscuit instead of a dinner roll. Staff interviews indicated a lack of clarity regarding portion sizes and menu adherence. The registered dietitian acknowledged that the menus were intended to provide 1700-1800 calories per day, but documentation showed that this was not always achieved. The cook was unaware of how desserts were portioned, and agreed that the servings were small. These findings demonstrate that the facility did not consistently provide adequate food to meet residents' nutritional needs, nor did it ensure that menus were properly followed and portioned.
Failure to Prevent Accidents and Implement Timely Interventions
Penalty
Summary
The facility failed to ensure that three residents remained free from accidents, leading to multiple incidents of fractures and falls. Resident #13, who had osteoporosis, sustained a right femur fracture that required hospitalization and surgery. The facility did not conduct a root cause analysis or implement timely person-centered interventions following this incident. Additionally, the facility delayed scheduling osteoporosis screening and treatment, which was recommended after the resident's surgical repair. Resident #13 later sustained another fracture, and again, the facility failed to document a root cause analysis or implement new interventions. Resident #17, identified as a high fall risk, experienced several unwitnessed falls resulting in injuries such as a concussion, laceration, and sacral insufficiency fractures. The facility updated the resident's fall care plan to include a floor mat at her bedside, but observations revealed inconsistent implementation of this intervention. After subsequent falls, the facility did not update the care plan with new interventions or conduct a thorough root cause analysis to prevent future falls. Resident #5 also experienced an incident where the facility failed to complete a thorough root cause analysis to determine how the resident obtained a skin tear. The facility's policy required documentation of all incidents and accidents, but the report indicates a lack of formal root cause analysis and implementation of person-centered interventions to prevent further incidents.
Failure to Obtain Physician's Orders and Document Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received appropriate care and services according to professional standards. Specifically, the facility did not obtain a physician's order for the use and maintenance of the resident's catheter upon admission and readmission, resulting in the absence of necessary orders in the resident's medical record until the issue was identified during the survey. The resident, who had diagnoses including end-stage renal disease, dementia, urinary retention, and obstructive and reflux uropathy, was dependent on staff for most activities of daily living and had a chronic Foley catheter in place. Observations and record reviews revealed that while staff reported performing routine catheter care and documenting it in the electronic medical record (EMR), there was no evidence of such documentation in the resident's catheter care records, treatment administration records (TAR), or progress notes for an extended period. Catheter care documentation was only marked as completed after new orders were entered during the survey. Additionally, urinary output was inconsistently recorded, with several days lacking any documentation and other days showing only once-daily entries instead of per shift as required. Interviews with CNAs, an RN, the infection preventionist, and the DON confirmed that catheter care should be performed and documented regularly, and that a physician's order should be present in the EMR. However, both the DON and infection preventionist acknowledged that the order for the urinary catheter was missed during the resident's readmission and was only added during the survey. The lack of documentation and missing physician's orders constituted a failure to provide care and services in accordance with professional standards and facility policy.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. According to CDC guidance and the facility's own policy, staff are required to don both gown and gloves during high-contact care activities for residents on EBP, including repositioning, changing linens, and providing incontinence or catheter care. Observations revealed that while some staff followed these procedures, the director of rehabilitation (DOR) did not wear a gown while assisting with repositioning and adjusting linens for the resident, despite direct contact with the resident and their bedding. The resident involved was observed lying in bed with a urinary catheter, and signage indicated EBP was in place. During peri-care, the DOR only donned gloves, not a gown, while assisting with repositioning and handling the resident's sheets and pillow. In contrast, a certified nurse aide (CNA) donned both gown and gloves for incontinence care. The DOR justified not wearing a gown by stating that only gloves were needed for basic care, despite the facility policy and infection preventionist (IP) stating that both gown and gloves were required for any high-contact care or when there was potential contact with bodily fluids or contaminated linens. Interviews with staff revealed inconsistent understanding and application of EBP protocols. While some CNAs and the IP correctly identified the need for gown and gloves during high-contact activities, others, including the DOR and another CNA, believed gowns were only necessary when directly handling urine or the catheter. The IP confirmed that education on EBP was ongoing and that staff had been provided with resources, but the observed failure to follow protocol during direct care activities led to the deficiency.
Failure to Monitor and Document Long-Term Antibiotic Use
Penalty
Summary
The facility failed to establish and maintain an effective antibiotic stewardship program, as evidenced by the lack of protocols and systems to monitor antibiotic use for two of six residents reviewed for antibiotic use. According to the CDC Core Elements of Antibiotic Stewardship for Nursing Homes and the facility's own policy, antibiotic use should be tracked, justified, and monitored, including documentation of clinical assessments, prescription details, and adherence to McGeer criteria. However, the facility did not consistently follow these protocols, resulting in deficiencies in monitoring and documentation. For one resident with a history of frequent urinary tract infections and severe cognitive impairment, the medical record showed ongoing prophylactic antibiotic therapy with nitrofurantoin. The physician's order lacked a specified duration and diagnosis, and there was no documented risk versus benefit analysis or physician justification for long-term use. Additionally, the infection preventionist (IP) did not complete an antibiotic use assessment or document that McGeer’s criteria were met. The resident’s long-term antibiotic use was not included in the facility’s infection surveillance documents, and staff interviews confirmed the absence of a process for physician review of prophylactic antibiotic use. Another resident, with diagnoses including cirrhosis and moderate cognitive impairment, was receiving long-term ciprofloxacin for abdominal infection. The medical record did not include documentation of side effect monitoring, completion of an antibiotic checklist, or infection surveillance reports for the prophylactic use of the antibiotic. The IP was unaware of the resident’s antibiotic use upon readmission and acknowledged that the case had not been tracked or monitored as required. These lapses demonstrate the facility’s failure to effectively track, monitor, and document antibiotic use in accordance with established protocols.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure the resident's environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents. A resident with advanced Huntington's disease, identified as a fall risk, was left unattended by a CNA who had raised the bed to a high position and removed the fall mat. The CNA left the room to find assistance for transferring the resident, during which time the resident fell out of bed, sustaining a head injury and a sacral fracture. The resident was sent to the hospital, received sutures, and later passed away, with the cause of death identified as decompensation following a mechanical fall. The resident's care plan included multiple interventions to prevent falls, such as the use of a low bed, fall mat, and helmets. Despite these interventions, the CNA did not follow the protocol of using the call light to request assistance and instead left the resident unattended. The facility's investigation confirmed that the CNA failed to adhere to the established safety protocols, which directly led to the resident's fall and subsequent injuries. Interviews with staff members, including CNAs and the DON, revealed that the facility had clear protocols for handling residents identified as fall risks. These protocols included using the call light to request assistance and never leaving a resident unattended. The CNA involved in the incident acknowledged the failure to follow these protocols, which resulted in the resident's fall and injuries. The facility's investigation and the death certificate confirmed that the fall and resulting injuries contributed to the resident's death.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pueblo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rock Canyon Respiratory And Rehabilitation Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Atlas Post Acute | 2.3 mi | ★★★★★ | 5 | 0 |
| Vista Ridge Care And Rehabilitation | 2.5 mi | ★★★★★ | 20 | 1 |
| Center At Park West Llc, The | 3.1 mi | ★★★★★ | 6 | 0 |
| Lakeshore Post Acute And Rehabilitation Center | 3.2 mi | ★★★★★ | 14 | 0 |
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