Above 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 Life Care Center Of Pueblo during CMS and state inspections, most recent first.
A resident on anticoagulant therapy with a history of falls and fragile skin was pushed in a wheelchair without foot pedals by a social services staff member, during which the resident’s foot dropped and the leg struck the wheelchair. The resident reported pain, and later a large hematoma was found on the lower leg, requiring ER evaluation, imaging, splinting, and repeated pain management. Documentation showed the hematoma enlarged over time and necessitated a second ER visit. During the survey, multiple other residents were observed being transported by CNAs, the IP, and housekeeping staff in wheelchairs without proper use of foot pedals, with feet dragging on the floor or positioned unsafely, despite staff acknowledging they knew pedals were needed to prevent injury. These actions and inactions demonstrated a pattern of unsafe wheelchair transport practices that led to the cited deficiency.
Surveyors identified multiple infection control failures involving hand hygiene, handling of drinkware and silverware, and mask use during a COVID-19 outbreak. CNAs refilled water pitchers and passed meal trays between residents without performing hand hygiene, including after directly handling a resident’s straw and assisting with dressing and food setup. Staff handled utensils by the tines and cutting surfaces, and cups by the rims, and used a knife that had just cut food to stir a resident’s coffee. During the same period, staff pulled masks down while in close contact with residents, wore masks below the mouth while assisting with meals, and did not perform hand hygiene after touching the outside of their masks, contrary to facility policy and CDC-based expectations.
A facility failed to treat residents with dignity and respect, as evidenced by incidents involving a CNA refusing to assist a non-weight-bearing resident, a bath aide neglecting care requests, and an LPN dismissing a resident's chest pain. Despite complaints, the issues persisted, leaving residents feeling humiliated and degraded.
A resident with a history of constipation experienced physical abuse when an RN continued a painful digital stool removal procedure despite the resident's pleas to stop. The incident was not documented in the resident's medical record, and the facility's investigation was inadequate. The resident's distress was corroborated by interviews with the resident, her roommate, and a CNA, but the facility ultimately unsubstantiated the claim of sexual abuse.
A resident reported being forcibly administered a suppository by an RN, leading to an inadequate investigation by the facility. The resident's account was supported by her roommate, but the facility failed to interview all relevant staff and did not explore the possibility of physical abuse. The investigation was compromised by a CNA conducting interviews instead of a qualified individual, and the facility unsubstantiated the abuse claim based on emergency department findings.
A resident was discharged AMA without proper documentation or coordination, leaving the representative to manage the discharge independently. The facility failed to provide discharge instructions, medications, or notify the physician, resulting in the resident missing essential medications for nearly two weeks.
A facility failed to follow and document bowel management protocols for a resident with a history of constipation and other medical conditions. The resident did not receive necessary laxatives or enemas after four days without a bowel movement, and the nurse did not document the administration of medications or procedures performed. Interviews confirmed the lack of documentation and adherence to standing orders.
The facility failed to complete annual performance reviews and provide regular in-service education based on the outcome of these reviews for five CNAs. The DON was unaware that performance reviews needed to include a regular in-service plan.
The facility failed to develop comprehensive care plans for two residents, neglecting to include dementia care plans and update fall care plan interventions. One resident had multiple unwitnessed falls without updates to the care plan, while another resident's care plan lacked a specific focus on dementia care despite their diagnosis. Staff interviews revealed inconsistencies in understanding and implementing care plan interventions.
The facility failed to ensure that inhalers were dated when opened, as observed in two of three medication carts. Both an RN and an LPN were unaware that the inhalers lacked open dates, which is necessary to ensure medication safety. The DON confirmed the importance of dating medications to ensure resident safety.
Failure to Use Wheelchair Foot Pedals Resulting in Hematoma and Ongoing Transport Hazards
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to wheelchair transport without foot pedals. One resident on anticoagulant therapy, with diagnoses including atrial fibrillation, history of falling, unsteadiness on feet, and fragile skin, used a wheelchair for mobility and had a care plan goal to minimize abnormal bleeding and bruising. Despite this, the resident was transported in a wheelchair without foot pedals by the social services director (SSD) when being taken to an activity in the dining room. During this transport, the resident’s foot dropped and her left leg hit the wheelchair. The SSD stopped, visually checked the leg, and did not see any marks, while the resident reported that her leg hurt but stated she still wanted to play bingo. The SSD then continued to assist the resident into the dining room and informed the nurse about the incident. Later that day, the resident complained of pain in the lower left leg and was given PRN pain medication. Subsequently, a large hematoma measuring approximately 8 inches by 4 inches was identified on the left calf, and the physician was notified, resulting in orders to hold the resident’s anticoagulant and to elevate and ice the leg. The resident was sent to the emergency room, where imaging showed soft tissue swelling without fracture, and she was treated and returned to the facility. The resident’s records documented ongoing severe pain, a progressively enlarging hematoma, and repeated assessments and treatments, including a splint and additional pain medications. The hematoma was later documented as 10 inches by 6 inches, and the resident required a second transfer to the emergency room for further evaluation. The DON acknowledged that foot pedals were likely not in use at the time of the initial incident and that no root cause analysis was conducted. In addition to this resident’s case, surveyor observations on multiple occasions showed other residents being transported by various staff (including CNAs, the infection preventionist, and housekeeping staff) in wheelchairs without proper use of foot pedals, with residents’ feet dragging on the floor or positioned unsafely between or off the pedals, demonstrating a broader pattern of unsafe wheelchair transport practices contributing to the deficiency. Staff interviews confirmed that they understood foot pedals were needed to prevent residents from bumping or dragging their feet or potentially falling, and that they had received education on this topic after a prior incident where a resident bumped a foot during wheelchair transport. Despite this knowledge, the observed practice during the survey period showed continued nonuse or improper use of wheelchair foot pedals when residents were being pushed, including residents lifting their feet to avoid dragging due to missing or flipped-up pedals. This pattern of actions and inactions—transporting a resident on anticoagulants without foot pedals leading to a significant hematoma and ongoing observations of similar unsafe transport for other residents—formed the basis of the cited deficiency for failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent accidents.
Inadequate Infection Control During Meal Service and COVID-19 Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene, handling of drinkware and silverware, and proper mask use during a COVID-19 outbreak. Surveyors observed that one CNA went from room to room collecting and refilling residents’ water pitchers without performing hand hygiene between rooms or after handling a resident’s straw. Another CNA assisted a resident with dressing, handled multiple residents’ meal trays, and then delivered and set up room trays for other residents without performing hand hygiene between residents or after direct contact with a resident and their food. Surveyors also observed improper handling of residents’ drinkware and silverware. One CNA pulled down the outside of his mask with his bare hand to speak with a resident, then used the same unwashed hand to hold the resident’s straw while encouraging her to drink, and continued refilling other residents’ water pitchers without hand hygiene. Another CNA unwrapped a resident’s silverware and held the fork and knife by the tines and cutting surface, grabbed the resident’s coffee mug by the rim to hand it to her, later grabbed the mug by the rim again to add sugar, and used the handle of the same knife that had been used to cut food to stir the resident’s coffee. During a period when the facility was in COVID-19 outbreak status, staff were also observed not donning face masks appropriately. One CNA repeatedly pulled his mask down by grabbing the outside of it while in close proximity to a resident’s face and did not perform hand hygiene after touching the mask, and his mask did not cover his mouth and nose while he was close to the resident. Another CNA wore a surgical mask pulled down below his mouth while assisting residents to their seats in the dining room and while sitting next to and assisting a resident with eating. These practices occurred despite facility policies and staff interviews confirming that hand hygiene should be performed before and after handling masks, that masks should cover both nose and mouth during an outbreak, and that staff should avoid touching areas of cups and utensils that contact residents’ mouths.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple incidents involving three residents. One resident, who was non-weight bearing due to a broken ankle, reported that a CNA was rude and refused to assist him with transfers to and from the toilet, leaving him feeling humiliated. The resident also experienced further disrespect when the CNA laughed at him and made derogatory comments in the dining room. Despite reporting these incidents to the nursing home administrator, the resident continued to feel bullied and disrespected by the CNA. Another resident reported that a bath aide refused to provide requested care, such as applying lotion and compression stockings after a shower, citing a lack of time. This resident also experienced delays in receiving meals and was told by staff that they did not have time to fulfill her requests for hot coffee, which made her feel unimportant and degraded. The resident expressed that complaints in the past had not led to any improvements, and she felt that staff gossiped about residents who complained. A third resident reported that an LPN did not treat her with respect and dignity, particularly when she experienced chest pain and felt that the LPN did not believe or care for her. This resident tried to avoid the LPN when she was on duty. The social service assistant acknowledged the resident's ability to communicate her needs and stated that staff were expected to treat residents with respect.
Failure to Protect Resident from Physical Abuse During Medical Procedure
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a registered nurse (RN) and a resident with a history of constipation. The resident, who was cognitively intact and receiving renal dialysis, requested assistance for constipation and was subjected to a painful procedure by RN #1. Despite the resident's cries and requests to stop, RN #1 continued to digitally remove stool from the resident's rectum, causing mental anguish and emotional distress. The incident was not documented in the resident's electronic medical record, and the facility's investigation into the matter was inadequate. Interviews with the resident, her roommate, and a certified nurse aide (CNA) corroborated the resident's account of the event, indicating that RN #1 did not heed the resident's pleas to stop the procedure. The facility's director of nursing (DON) acknowledged that RN #1 should have stopped the procedure when the resident requested it and should have documented the event in the medical record. The resident's representative reported the incident to the dialysis center social worker, who then notified adult protective services. The facility's nursing home administrator (NHA) was informed of the allegation and initiated an investigation, but the facility ultimately unsubstantiated the claim of sexual abuse. The emergency department visit following the incident noted mild redness in the resident's rectum but no overt trauma. The lack of proper documentation and response to the resident's distress highlights a significant deficiency in the facility's handling of the situation.
Inadequate Investigation of Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported being held down and forcibly administered a suppository by a registered nurse (RN). The resident, who was cognitively intact and had a history of constipation, reported the incident to her representative, stating that she was crying out for the nurse to stop but was ignored. The resident's roommate corroborated the account, stating that the resident had repeatedly yelled for the RN to stop and appeared to be in distress. The facility's investigation into the incident was inadequate, as it did not include interviews with all staff members present during the incident. Only one additional staff member working at the time was interviewed, and the investigation failed to explore the possibility of physical abuse despite the resident's claims of being hurt and asking the nurse to stop. The facility also did not ask other residents if they had experienced care that felt forceful, focusing instead on questions about sexual inappropriateness and safety. The investigation was further compromised by the involvement of a certified nurse aide (CNA) in conducting interviews, rather than a qualified social worker or management team member. The director of nursing (DON) recused herself from the investigation due to a conflict of interest, as the RN involved was her sister, but did not ensure that a qualified individual conducted the necessary interviews. The facility ultimately unsubstantiated the sexual abuse allegation based on the emergency department's findings, which noted no trauma, but failed to address the potential for physical abuse.
Failure to Implement Effective Discharge Plan
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident who was discharged against medical advice (AMA). The resident, who was cognitively intact and required a Hoyer lift for transfers due to a recent left leg below the knee amputation, was discharged without proper documentation or coordination with the interdisciplinary team (IDT). The facility's policy required documentation of decision-making capacity, risks, and discharge instructions, but these were not provided. The resident's electronic medical record (EMR) lacked documentation of discharge goals, reasons for the AMA discharge, and notification of the resident's physician or medical director. The resident's representative, who was a certified nurse aide and emergency medical technician, reported that the facility did not assist in the discharge planning process. The representative stated that the facility forced her to sign AMA paperwork and did not provide discharge instructions, medications, or a list of current medications. As a result, the resident went nearly two weeks without essential medications. The facility also failed to notify adult protective services (APS) about the AMA discharge, which was standard practice. Interviews with facility staff revealed that the director of nursing (DON) and the social services director (SSD) acknowledged the lack of proper discharge documentation and coordination. The SSD, who was newly employed, noted that the social worker should have led the discharge planning process and offered necessary services and referrals. The medical director confirmed that a physician's discharge order should have been obtained, and the attending physician should have been involved in the AMA discharge process. The dialysis center social worker also indicated that the facility did not provide a safe discharge, leaving the resident's representative to manage the discharge independently.
Failure to Document and Follow Bowel Management Protocols
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident reviewed for quality of care. Specifically, the facility did not follow the physician's standing orders for bowel management for the resident, who had a history of constipation and other medical conditions such as gastro-esophageal reflux disease, diabetes mellitus type 2, and end-stage renal disease. The resident's representative expressed concern about the resident's bowel regimen due to a family history of bowel obstruction. The facility did not document the administration of bowel medications, nursing medication reassessment, abdominal and peri-rectal assessments, or the digital fecal disimpaction procedure for the resident. The medication administration record showed that the resident did not receive any as-needed laxatives, softeners, or enemas after going four days without a bowel movement. The electronic medical record lacked documentation of the registered nurse's assessment of the resident's bowel status or the procedures performed. Interviews with staff revealed that the registered nurse did not document the administration of milk of magnesia, Miralax, or a suppository, despite performing these actions. The nurse also failed to document the abdominal and rectal assessments, digital stool removal, and fecal disimpaction. The director of nursing confirmed that all medications and treatments should be documented in the medical administration record when given.
Failure to Complete Annual Performance Reviews and Provide In-Service Education
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five staff reviewed. Specifically, CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5 did not have an annual performance review completed, nor did they have an in-service education plan based on the outcome of the review. During an interview, the DON stated she was not aware that performance reviews needed to include a regular in-service plan based on the outcome of these reviews.
Failure to Develop Comprehensive Care Plans for Residents with Dementia
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, specifically neglecting to include dementia care plans and update fall care plan interventions. Resident #63, who was moderately cognitively impaired and at risk for falls, had multiple unwitnessed falls in 2024. Despite these incidents, the care plan was not updated with new interventions, and the existing interventions were not effectively communicated to the staff. Interviews with staff revealed inconsistencies in the understanding and implementation of the care plan interventions for Resident #63. Resident #6, diagnosed with dementia and neurocognitive disorder with Lewy bodies, had a care plan that included interventions for psychotropic medication but lacked a specific focus on dementia care. The care plan did not address the resident's cognitive decline or behaviors related to dementia. Staff interviews confirmed the absence of a dementia-specific focus in the care plan, despite the resident's diagnosis and needs. The facility's policies on incident management and dementia care were not followed, as evidenced by the lack of updates to the care plans and the failure to develop person-centered interventions. The Director of Nursing and other staff acknowledged the deficiencies in the care plans, indicating a systemic issue in the facility's approach to care planning and communication among staff.
Failure to Date Opened Inhalers
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional standards for two of three medication carts. Specifically, the facility did not date inhalers when they were opened, which is necessary to ensure the safety and efficacy of the medication. During an observation of the H hall medication cart with a registered nurse (RN), a Trelegy inhaler was found without an open date. The RN admitted to not knowing the inhaler was expired and acknowledged that it should have been dated to ensure safety. Similarly, an observation of the G hall medication cart with a licensed practical nurse (LPN) revealed an open Incruse inhaler and Wixela inhaler, both of which were not dated when opened. The LPN also admitted to being unaware that the inhalers lacked an open date and emphasized the importance of dating them to ensure safe administration to residents. The director of nursing (DON) confirmed in an interview that it is crucial for all medications to be dated when opened and discarded when expired to ensure resident safety. The failure to date the inhalers when opened was a clear deviation from the manufacturer's guidelines, which specify the time frame within which the inhalers should be discarded after opening. This oversight in labeling and storage practices led to the deficiency identified by the surveyors.
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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) |
|---|---|---|---|---|
| Atlas Post Acute | 1.8 mi | ★★★★★ | 5 | 0 |
| Rock Canyon Respiratory And Rehabilitation Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Lakeshore Post Acute And Rehabilitation Center | 2.2 mi | ★★★★★ | 14 | 0 |
| High Plains Post Acute Llc | 3.3 mi | ★★★★★ | 6 | 0 |
| Vista Ridge Care And Rehabilitation | 5.7 mi | ★★★★★ | 20 | 1 |
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