5
Inspections
2
Deficiencies
0
Actual Harm or Above
15
Occurrences
February 18, 2026
Last Inspection
S/S B Minimal potential
The most recent inspection of PUEBLO WEST GARDENS ASSISTED LIVING on record is dated February 18, 2026. Across 5 published inspections, state surveyors cited 2 deficiencies, none of which reached the actual-harm level.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
Assisted Living Residence/Alternative Care Facility (Medicaid)
Administrator
Schilling, Daphine
Owner
PUEBLO WEST GARDENS LLC
Phone
(719) 924-8624
Payor Source
Medicaid, Private Pay
City
PUEBLO WEST
ZIP
81007
Inspections & Citations
5 inspections · 2 deficiencies2/18/2026Licensure (Re-licensure) · ID L0G111No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 2/18/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
2/26/2024Revisit: State Certification and State Certification Complaint (Combined) · ID 297S12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 2/26/24 for all previous deficiencies cited on 10/11/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
2/26/2024Revisit: Licensure and Licensure Complaint (Combined) · ID Z94U12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 2/26/24 for all previous deficiencies cited on 10/11/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
10/10/2023State Certification and State Certification Complaint (Combined) · ID 297S111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A recertification survey with complaints #CO33171, #CO33253, #CO33470, was completed on 10/11/23. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼
Findings
Based on observation, record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting two of three sample participants (residents) (#2, #3). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.29, requires each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event iscompleted for each resident. Residence Policy The residence's undated Medication Administration policy, read in part, "The qualified medication administration person (QMAP) will document each medication administration ..." a. Resident #2 was admitted to the residence on 10/3/11. Olanzapine A written practitioner's order, dated 1/15/23, directed the residence to administer olanzapine 15 mg one tablet daily. However, the September and October 2023 MAR revealed a blank space on 9/2, 9/3, 9/15, 10/1, and 10/2/23, for a total of five inaccurately documented doses. Breztri InhalerA written practitioner's order, dated 1/15/23, directed the residence to administer two puffs of the Breztri inhaler twice daily. However, the September 2023 MAR revealed a blank space on 9/8/23 for the afternoon dose, for a total of one inaccurately documented dose.b. Resident #3 was admitted to the residence on 5/13/19. Oxycodone A written practitioner's order, dated 1/12/23, directed the residence to administer oxycodone 10 mg one tablet every morning. However, the September 2023 MAR revealed a blank space on 9/6 and 9/28/23, for a total of two inaccurately documented doses. LevothyroxineA written practitioner's order, dated 1/15/23, directed the residence to administer levothyroxine 50 mcg one tablet daily. However, the September and October MARs revealed a blank space on 9/6, 9/18, and 10/6/23, for a total of three inaccurately documented doses. Buspirone A written practitioner's order, dated 1/15/23, directed the residence to administer buspirone 10 mg two tablets three times daily. However, the September MAR revealed a blank space for the afternoon doses on 9/11 and 9/15/23, for a total of two inaccurately documented doses.c. Interviews On 10/11/23 at 9:45 a.m., the resident care coordinator (RCC) stated the QMAPs were expected to document all medication administrations at the time of administration. She stated she was unsure if the medications had been administered to Residents #2 and #3 on the dates in question and confirmed the medication were not accurately documented as required. In a subsequent interview with the RCC at 10:30 a.m., she confirmed the medications had been administered to Residents #2 and #3, however, the medication administration was not documented as required. On 10/11/23 at 11:15 a.m., the administrator stated all the QMAPs were trained and expected to document medication administrations at the time of administration. Additionally, she stated the QMAPs were expected to document refusals, when the resident was out of the residence, or if the medication was out and waiting to be delivered.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PEPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE. A description of how the licensee will correct each identified deficiency. A full medication audit was performed immediately to ensure that all identified deficiencies were corrected. The facility will ensure prescriptions are available with current orders and practices are in place to administer prescribed medications to residents in the required time frame following the prescribed orders and documenting the medication administration timely as required under the state regulations. A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. The Resident Care Coordinator (RCC) will run a “No Pass Report“ in the electronic medication tracking system 3 times a week to validate/ ensure medications have been administered as prescribed and timely documented in our system. These reports will be logged and reviewed weekly by the Administrator and/or Compliance Manager. The facilities QMAPs will be required once a shift to complete a report identifying their med pass that have not been documented in a timely manner and report to the RCC the documentation. All delayed passes will be reported, and an incident report will be completed. The monitoring logs and incident reports will be reviewed weekly for the first month and every other week thereafter for the next 3 months by the Administrator and the Compliance Manager. The written monitoring logs and incident reports will be reviewed monthly by the Administrator with the Quality Management Team. A completion date that shall be no longer than (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department. The facility will have implemented all corrective actions described in this plan of correction by 11/05/2023.
10/10/2023Licensure and Licensure Complaint (Combined) · ID Z94U111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaints #CO33169, #CO33252, #CO33469 was completed on 10/11/23. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1510Med/Med Adm-Rcrd Kpng MARS/S B▼
Findings
Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting two of three sample residents (#2, #3). Findings include: 1. Residence Policy The residence's undated Medication Administration policy, read in part, "The qualified medication administration person (QMAP) will document each medication administration ..." 2. Resident #2 was admitted to the residence on 10/3/11. a. Olanzapine A written practitioner's order, dated 1/15/23, directed the residence to administer olanzapine 15 mg one tablet daily. However, the September and October 2023 MAR revealed a blank space on 9/2, 9/3, 9/15, 10/1, and 10/2/23, for a total of five inaccurately documented doses.b. Breztri InhalerA written practitioner's order, dated 1/15/23, directed the residence to administer two puffs of the Breztri inhaler twice daily. However, the September 2023 MAR revealed a blank space on 9/8/23 for the afternoon dose, for a total of one inaccurately documented dose. 3. Resident #3 was admitted to the residence on 5/13/19. a. Oxycodone A written practitioner's order, dated 1/12/23, directed the residence to administer oxycodone 10 mg one tablet every morning. However, the September 2023 MAR revealed a blank space on 9/6 and 9/28/23, for a total of two inaccurately documented doses.b. LevothyroxineA written practitioner's order, dated 1/15/23, directed the residence to administer levothyroxine 50 mcg one tablet daily. However, the September and October MARs revealed a blank space on 9/6, 9/18, and 10/6/23, for a total of three inaccurately documented doses.c. Buspirone A written practitioner's order, dated 1/15/23, directed the residence to administer buspirone 10 mg two tablets three times daily. However, the September MAR revealed a blank space for the afternoon doses on 9/11 and 9/15/23, for a total of two inaccurately documented doses. 4. Interviews On 10/11/23 at 9:45 a.m., the resident care coordinator (RCC) stated the QMAPs were expected to document all medication administrations at the time of administration. She stated she was unsure if the medications had been administered to Residents #2 and #3 on the dates in question and confirmed the medication were not accurately documented as required. In a subsequent interview with the RCC at 10:30 a.m., she confirmed the medications had been administered to Residents #2 and #3, however, the medication administration was not documented as required. On 10/11/23 at 11:15 a.m., the administrator stated all the QMAPs were trained and expected to document medication administrations at the time of administration. Additionally, she stated the QMAPs were expected to document refusals, when the resident was out of the residence, or if the medication was out and waiting to be delivered.
Plan of correction · submitted by the facility
PREPARATION AND EXECUTION OF THIS RESPONSE AND PLAN OF CORRECTION DOES NOT CONSTITUTE AN ADMISSION OR AGREEMENT BY THE PROVIDER OF THE TRUTH OF THE FACTS ALLEGED OR CONCLUSIONS SET FORTH IN THE STATEMENT OF DEFICIENCIES. THE PLAN OF CORRECTION IS PREPARED AND/OR EXECUTED SOLELY BECAUSE IT IS REQUIRED BY THE PROVISIONS OF STATE LAW. FOR THE PURPOSES OF ANY ALLEGATION THAT THE FACILITY IS NOT IN SUBSTANTIAL COMPLIANCE WITH RESPECT TO ANY STATE REQUIREMENTS AS A LICENSED ASSISTED LIVING RESIDENCE, THIS RESPONSE AND PLAN OF CORRECTION CONSTITUTES THE FACILITY’S CONFIRMATION OF SUCH SUBSTANTIAL COMPLIANCE UNDER 6 CCR 1011-1, CHAPTER 7. A description of how the licensee will correct each identified deficiency. A full medication audit was performed immediately to ensure that all identified deficiencies were corrected. The facility will ensure prescriptions are available with current orders and practices are in place to administer prescribed medications to residents in the required time frame following the prescribed orders and documenting the medication administration timely as required under the state regulations. A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not reoccur. The Resident Care Coordinator (RCC) will run a “No Pass Report“ in the electronic medication tracking system 3 times a week to validate/ ensure medications have been administered as prescribed and timely documented in our system. These reports will be logged and reviewed weekly by the Administrator and/or Compliance Manager. The facilities QMAPs will be required once a shift to complete a report identifying their med pass that have not been documented in a timely manner and report to the RCC the documentation. All delayed passes will be reported, and an incident report will be completed. The monitoring logs and incident reports will be reviewed weekly for the first month and every other week thereafter for the next 3 months by the Administrator and the Compliance Manager. The written monitoring logs and incident reports will be reviewed monthly by the Administrator with the Quality Management Team. A completion date that shall be no longer than (30) calendar days from the issuance of the deficiency list, unless otherwise required or approved by the Department. The facility will have implemented all corrective actions described in this plan of correction by 11/05/2023.
Reportable Occurrences
15 records5/15/2026Misappropriation of Property · ID 2623Z781004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/15/26 the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) reported having $400 in a safe and that $110 had been stolen. Client (A) reported last seeing the money on 5/5/26. During the course of the investigation, the healthcare entity searched for the item, conducted interviews, and reviewed records. Staff discovered $290 remained in the safe. Interviews revealed that another client gave client (A) $110 to complete a task which they did not complete, so the $110 was returned to that client. The facility educated client (A) on keeping their room secured and documenting all monetary transactions. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/7/2026 · released to the public 7/14/2026.
3/16/2026Neglect · ID 2623Z781003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/16/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. Staff (1) administered client (A) a duplicate dose of their pain medication. This created significant potential for harm. During the course of the investigation, the healthcare entity suspended staff (1) from medication administration duties, contacted medical providers, conducted interviews, and reviewed records. Client (A) experienced adverse effects from the duplicate medication dose, and emergency medical services (EMS) were contacted for evaluation. EMS provided treatment options. Staff (1) confirmed the incident. The facility implemented increased checks and held client (A)'s medications for a period of time per their medical provider's direction. The facility required staff (1) to retake their qualified medication administration personnel course and retrained all staff on medication administration. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/15/2026 · released to the public 5/22/2026.
1/31/2026Sexual Abuse · ID 2623Z781002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/13/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. Client (A) alleged that a visitor made sexual advances towards them when out in the community together. During the course of the investigation, the healthcare entity ensured that client (A) was safe and did not have contact with the alleged visitor. The facility contacted the police and conducted interviews. Client (A) could not recall a definitive date of the sexual comment and later stated they were never touched or harmed. Client (A)'s power of attorney reported that this allegation had been made towards other visitors in the past. The visitor denied the allegation and no longer wished to see client (A). Staff reported they never observed client (A) to be upset when returning to the facility after the outings with the visitor. The facility instructed client (A) to immediately report these events. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 4/3/2026 · released to the public 4/10/2026.
12/14/2025Neglect · ID 2523Z781012Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/14/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. During a medication count, staff determined a medication for one client was administered to another client, Client (A), causing minimal side effects in Client (A). During the course of the investigation, the healthcare entity notified Client (A)’s medical provider, removed the responsible staff from duty, reviewed records, and conducted interviews. Client (A) was monitored following the incident and recovered. The staff member responsible for the error was placed on probation for several months and did not administer medications. The facility also reported the staff member completed retraining because they did not follow facility policy for safe medication administration. Although none was reported, there was significant potential for harm. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/23/2026 · released to the public 3/30/2026.
9/29/2025Physical Abuse · ID 2523Z781010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/13/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (A) alleged they were physically assaulted a few weeks ago in their sleep and sustained mount injuries. During the course of the investigation the healthcare entity ensured Client (A) felt safe before the police were notified. The victim had recently been seen by a dentist who prescribed medication due to a mouth infection. The client could not indicate who the assailant was. The facility implemented increased monitoring and the client was educated to report any allegations immediately. No findings by the sheriff. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/4/2026 · released to the public 3/11/2026.
9/18/2025Missing Person · ID 2523Z781008Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/18/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a missing client. Staff observed that client (A) was missing from the facility after conducting a search. Client (A) had a history of elopement and homelessness. The facility had implemented a safety contract with client (A) on 9/15/25 to help prevent another missing persons event. This was the third missing persons event in three weeks (refer to earlier case ID#s 2523Z781006 and 2523Z781007 for further details). During the course of the investigation, the healthcare entity contacted client (A)'s family and police. After 72 hours, client (A) returned to the facility. As client (A) did not follow the safety contract that he signed back on 9/15/25, management issued an involuntary discharge notice. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 2/5/2026 · released to the public 2/12/2026.
9/8/2025Missing Person · ID 2523Z781007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/8/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a missing client. Staff observed that client (A) was missing from the facility after conducting a search. Client (A) had a history of elopement and homelessness. During the course of the investigation, the healthcare entity contacted police, client (A)'s family, and local emergency departments. Client (A) was found by his family 36 hours later and returned to the facility. The facility developed a safety plan to help prevent a reoccurrence and attempted to implement it; however, client (A) had left the facility again prior to it being implemented. The event was substantiated. This is the second report of a missing persons event involving this client. Please refer to case ID # 2523Z781006 for details. Approximately 10 days after this report, client (A) left the facility again and was identified as a missing person. Refer to case ID# 2523Z781008 for more information. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 2/5/2026 · released to the public 2/12/2026.
9/1/2025Missing Person · ID 2523Z781006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/1/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a missing client. Client (A) was missing from the facility and did not sign out. The client was missing for more than 12 hours. During the course of the investigation the healthcare entity conducted a search and interviewed clients and staff. The police were notified, and the client was found at a nearby park without any injuries. Staff implemented safety checks, the client was educated to sign out, and the family implemented weekly visits and bringing the client things they requested. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 1/7/2026 · released to the public 1/14/2026.
8/31/2025Physical Abuse · ID 2523Z781005Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/31/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed Client (A) and (B) in a physical altercation. Client (B) struck Client (A) in the face before Client (A) pushed back. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) did not want to be assessed and no injuries were seen to their person. Both clients will be redirected when necessary and they have been educated to seek staff for assistance with concerns. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 1/18/2026 · released to the public 1/26/2026.
6/26/2025Sexual Abuse · ID 2523Z781004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 8/26/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported sexual abuse of a client. Client (A) alleged a few months ago Staff #1 had performed inappropriate sexual gestures in front of them. During the course of the investigation the healthcare entity ensured the client was safe. The police were notified and did not take the case any further as the client did not want to continue with the investigation and stated they were never touched inappropriately. Staff #1 stated they were rarely in the same area as the client and denied the allegation. Staff #1 did not return to the facility and resigned from their position. All clients were educated on reporting concerns immediately. The event was inconclusive and not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 12/9/2025 · released to the public 12/16/2025.