10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Pueblo, CO
3-star overall rating with 3-star inspections with $48,912 in total fines with 10 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
855 Hunter Dr, Pueblo, CO
(719) 253-3700
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
90
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Frontline Management
Operator or chain grouping
Approved since
1973-05-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.86
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
87%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
5,994
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.99
Baseline 18.17% · Performance 18.19% · Measure score 6.99 · Achievement 6.99 · Improvement 0
Healthcare-associated infections
1.46
Baseline 6.15% · Performance 7.40% · Measure score 1.46 · Achievement 1.46 · Improvement 0
Total nurse turnover
4.67
Baseline 52.94% · Performance 44.59% · Measure score 4.67 · Achievement 4.67 · Improvement 2.47
Adjusted total nurse staffing
0.62
Baseline 3.68 hours · Performance 3.25 hours · Measure score 0.62 · Achievement 0.62 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 152 · Observed rate 7.89% · Lower 95% interval 7.23% |
| Discharge to community | 50.49% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 158 · Observed rate 44.3% · Lower 95% interval 42.92% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.8% |
95.27%
3.5 pts better
|
Numerator 82 · Denominator 83 |
| Falls with major injury | 1.2% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 83 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 24 · Denominator 54 |
| Discharge mobility score | 37.04% |
50.94%
13.9 pts worse
|
Numerator 20 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 1.2% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 83 · Adjusted rate 0.92% |
| Healthcare-associated infections requiring hospitalization | 7.4% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 7.53% · Lower 95% interval 4.5% |
| Staff COVID-19 vaccination coverage | 4.72% |
8.2%
3.5 pts worse
|
Numerator 6 · Denominator 127 |
| Staff flu vaccination coverage | 89.87% |
42%
47.9 pts better
|
Numerator 142 · Denominator 158 |
| Discharge function score | 37.04% |
56.45%
19.4 pts worse
|
Numerator 20 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 22.86% |
25.2%
2.3 pts worse
|
Numerator 8 · Denominator 35 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.3
0.5 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.4% |
93.5%
18.1 pts worse
|
93.4%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 82.0% · Q3 69.6% · Q4 68.3% · 4Q avg 75.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.4%
1.8 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.9% · Q3 3.6% · Q4 6.7% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
7.4%
7.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
5.0%
4 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 1.9% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.1% |
11.2%
5.1 pts better
|
19.6%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.6% · Q3 7.7% · Q4 7.1% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.6% |
20.6%
2 pts worse
|
16.7%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 22.0% · Q3 23.3% · Q4 21.4% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.1% |
15.2%
1.9 pts worse
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 31.3% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.1% |
14.6%
3.5 pts worse
|
14.9%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 20.4% · Q3 26.7% · Q4 24.0% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.8%
0.1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
1.5%
3 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 5.3% · Q3 0.0% · Q4 3.4% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
22.4%
2.2 pts better
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 24.6% · Q3 22.7% · Q4 16.7% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
3.7%
1.4 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.0% · Q3 8.7% · Q4 7.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.8% |
76.4%
16.6 pts worse
|
81.7%
21.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.0% · Q2 63.0% · Q3 48.7% · Q4 45.2% · 4Q avg 59.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
12.8%
2.5 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 14.5% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.7% |
75.6%
17.9 pts worse
|
79.7%
22 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
20.3%
3.2 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 16.4% · Expected 22.8% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2026-02-03
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-12-26
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-12-26
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-12-26
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-12-26
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-26
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-12-26
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-12-26
Fire Safety
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.
Corrected 2026-02-03
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-26
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-12-26
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-12-26
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-26
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-10
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-10
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-10
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-20
Inspection history
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-05
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-05
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-12-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-05
Health
Implement a program that monitors antibiotic use.
Corrected 2025-12-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-11
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-11
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-11
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-11
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-01-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-11
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-11
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-11
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-09-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-06
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-09-06
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-10-01
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-01
Health
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.
Corrected 2022-10-01
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-01
Health
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.
Corrected 2022-10-01
Health
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.
Corrected 2022-10-01
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-10-01
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-10-01
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-10-01
Penalties and ownership
Fine · fine $20,400
Fine
Payment Denial · denial start 2026-01-01 · 33 days
33 day denial
Fine · fine $28,512
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Nearby options
Pueblo, CO
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Pueblo, CO
4-star overall rating with 3-star inspections with $22,653 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Pueblo, CO
3-star overall rating with 2-star inspections with $72,840 in total fines with 11 recent health deficiencies
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