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Public Record

The Pavilion at Villa Pueblo

Nursing HomePueblo, COCMS 065121
54 citations on record

From CMS

Facility profile

CMS overall rating
3 / 5

*CMS Five-Star

Certified beds
90

*CMS

Avg. residents per day
73.2

*CMS

Inspection record

On record from CMS

Citations on record
54

*CMS

Inspections on file
8

*CMS

Last inspection
2025-12-04

*CMS

Citations

54 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0291Generalpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0812Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0881Generalpotential for harm

    Implement a program that monitors antibiotic use.

  • 0325Generalpotential for harm

    Have properly installed hallway dispensers for alcohol-based hand rub.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0293Generalpotential for harm

    Have properly located and lighted "Exit" signs.

  • 0222Generalpotential for harm

    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.

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0161Seriousimmediate jeopardy

    Use approved construction type or materials.

  • 0374Generalpotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0362Generalpotential for harm

    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0605Generalpotential for harm

    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0804Generalpotential for harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0341Generalpotential for harm

    Install a fire alarm system that can be heard throughout the facility.

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0658Generalpotential for harm

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

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0812Generalpotential for harm

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

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0686Seriousactual harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0689Generalpotential for harm

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

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0725Generalpotential for harm

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0293Generalpotential for harm

    Have properly located and lighted "Exit" signs.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0676Generalpotential for harm

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  • 0882Generalpotential for harm

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  • 0812Generalpotential for harm

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

  • 0760Generalpotential for harm

    Ensure that residents are free from significant medication errors.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0690Generalpotential for harm

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0689Seriousactual harm

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

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0688Generalpotential for harm

    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.

  • 0686Seriousactual harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0578Generalpotential for harm

    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.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0761Generalpotential for harm

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

FAQ

Questions and answers

What is The Pavilion at Villa Pueblo?
The Pavilion at Villa Pueblo is a Medicare- and Medicaid-certified nursing home in Pueblo, CO, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 065121.
What is the CMS rating for The Pavilion at Villa Pueblo?
The Pavilion at Villa Pueblo has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does The Pavilion at Villa Pueblo have?
The Pavilion at Villa Pueblo is certified for 90 beds. It serves an average of 73.2 residents per day.
How many citations does The Pavilion at Villa Pueblo have?
The Pavilion at Villa Pueblo has 54 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was The Pavilion at Villa Pueblo last inspected?
The Pavilion at Villa Pueblo was last inspected on December 4, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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