Pavilion At Villa Pueblo, The faces challenges in its CMS ratings, earning a D grade with a score of 46/100. The facility ranks in the 39th percentile among Colorado nursing homes, suggesting significant room for improvement.
Staffing at Pavilion At Villa Pueblo, The is near the national average, with 3.49 total nursing hours per resident per day (national average: 3.8 hours).
Recent inspections identified 31 deficiencies at Pavilion At Villa Pueblo, The. While none were classified as the most serious level, families should review the detailed inspection history below.
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.49 | 3.8 | Average |
| Registered Nurses (RN) | 0.86 | 0.7 | Above Average |
| Licensed Practical Nurses (LPN) | 0.58 | 0.7 | Below Average |
| Certified Nursing Assistants (CNA) | 2.05 | 2.4 | Below Average |
| Weekend Total Nursing | 3.26 | 3.8 | Below Average |
| Weekend RN Hours | 0.78 | 0.7 | Above Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0804 Severity EEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.Dec 3, 2025 · Nutrition and Dietary Deficiencies
- Tag 0812 Severity EProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Dec 3, 2025 · Nutrition and Dietary Deficiencies
- Tag 0880 Severity EProvide and implement an infection prevention and control program.Dec 3, 2025 · Infection Control Deficiencies
- Tag 0605 Severity DPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Dec 3, 2025 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
- Tag 0684 Severity DProvide appropriate treatment and care according to orders, resident’s preferences and goals.Dec 3, 2025 · Quality of Life and Care Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 5.1% | 4.5% | Worse |
| Falls with major injury | 5.2% | 3.0% | Worse |
| On antipsychotic medication | 22.6% | 14.5% | Worse |
| Urinary tract infections | 4.5% | 2.5% | Worse |
| ADL decline (daily activities) | 18.1% | 14.0% | Worse |
| Excessive weight loss | 1.0% | 7.5% | Better |
| New/worsened incontinence | 20.2% | 45.0% | Better |
⚠️ Penalties & Fines
2 penalties recorded by CMS
Total fines: $48,912
How This Grade Was Calculated
This facility's grade of D is based on a score of 46 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 3★ → 24 pts (max 40)
- Health Inspection Rating: 3★ → 15 pts (max 25)
- Staffing Rating: 3★ → 12 pts (max 20)
- Quality Measures Rating: 3★ → 9 pts (max 15)
- Penalty deductions: -10 pts
- Fine deductions: -4 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
Other Facilities in Colorado
- F
- F
- FMOUNTAIN VISTA HEALTH CENTERWHEAT RIDGE
- DAMBERWOOD POST ACUTEDENVER
- DBOULDER POST ACUTEBOULDER