The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited December 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
PAVILION AT VILLA PUEBLO, THE
PUEBLO, CO · Medicare-certified · 90 beds
Needs attention
For-profitChain member
3 of 5 overall
3 of 5 stars overall. Staffing is a concern at 2 of 5 stars, with reported nurse staffing at 3.32 hours per resident per day below the 4.1 federal benchmark; the facility also had $13,260 in fines in the last 24 months and a recent federal penalty, with cited issues involving pressure ulcer care, accident hazards, and infection prevention and control.
Facility ratings
Health inspections
Staffing
3.3244 hrs/resident/day
Quality measures
Last inspection: December 4, 2025Penalties, last 24 months: $13,260recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.3244.
Staffing detail
- Registered nurses
- 0.87
- Licensed practical nurses
- 0.47
- Nurse aides
- 1.99
- Weekend nursing
- 3.02
Hours per resident per day.
Total staff turnover: 67%
Registered nurse turnover: 83%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
20%17.5%Improving
Residents with a fall causing major injury
4.9%9.5%Worsening
Residents with pressure ulcers (bedsores)
3%2.9%No change
Residents with a urinary tract infection
5.3%1.6%Improving
Residents who lost too much weight
2%1.8%No change
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
20.4%22.6%Worsening
Residents whose ability to walk got worse
—31.3%—
Long-stay residents on antianxiety or sleep medication
5.6%8.8%Worsening
Short-stay residents newly given an antipsychotic
0%0%No change
Residents with a long-term catheter
0%1%Worsening
Residents with new or worsening incontinence
24.6%26.2%Worsening
Residents with depressive symptoms
0%2%Worsening
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
82%98.4%Improving
Short-stay residents given the seasonal flu vaccine
—57.7%—
Short-stay residents given the pneumonia vaccine
63%55.1%Worsening
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited September 2022 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited December 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: F
The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited December 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 725 — 42 CFR §483.35 — S/S: F
The nursing home failed to ensure a qualified person was assigned to oversee infection prevention and control. Cited August 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 882 — 42 CFR §483.80 — S/S: F
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal fine of $13,260 was recorded.
- INSPECTION
Health inspection found 6 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 7 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 2 fines · $41,772 in total fines · 1 payment denial.
- 33 days
Medicare/Medicaid payment denial
Dec 4, 2025
- $13,260
Federal fine
Dec 4, 2025
- $28,512
Federal fine
Dec 14, 2023
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of FRONTLINE MANAGEMENT · 9 homes · 3.3 stars avg
- Occupancy
- 73.2 residents on an average day (81% of 90 beds)
- Resident voice
- Resident & family councils
- Medicare history
- Certified for 53 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.