Pueblo, CO
1-star overall rating with 2-star inspections with abuse icon flag with $89,938 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2515 Pitman Pl, Pueblo, CO
(719) 564-0550
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
151
Certified beds
Average residents
134
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1968-03-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.56
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.74
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
2.55
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
11,530
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.49
Baseline 19.31% · Performance 20.28% · Measure score 2.49 · Achievement 2.49 · Improvement 0
Healthcare-associated infections
0
Baseline 7.28% · Performance 8.72% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.08
Baseline 47.06% · Performance 47.00% · Measure score 4.08 · Achievement 4.08 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.64 hours · Performance 2.45 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 13.7% · Lower 95% interval 7.21% |
| Discharge to community | 37.32% |
50.57%
13.2 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 26.42% · Lower 95% interval 27.32% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 52 · Denominator 52 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 52 |
| Discharge self-care score | 57.58% |
53.69%
3.9 pts better
|
Numerator 19 · Denominator 33 |
| Discharge mobility score | 51.52% |
50.94%
0.6 pts better
|
Numerator 17 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 5.77% |
2.29%
3.5 pts worse
|
Numerator 3 · Denominator 52 · Adjusted rate 4.87% |
| Healthcare-associated infections requiring hospitalization | 8.73% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 17.02% · Lower 95% interval 4.95% |
| Staff COVID-19 vaccination coverage | 4.57% |
8.2%
3.6 pts worse
|
Numerator 8 · Denominator 175 |
| Staff flu vaccination coverage | 90.63% |
42%
48.6 pts better
|
Numerator 232 · Denominator 256 |
| Discharge function score | 75.76% |
56.45%
19.3 pts better
|
Numerator 25 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 54.17% |
25.2%
29 pts better
|
Numerator 13 · Denominator 24 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.3
0.8 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 2.7% |
3.4%
0.7 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 3.4% · Q3 2.5% · Q4 4.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
7.4%
1.5 pts worse
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 12.8% · Q3 17.6% · Q4 3.8% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.0%
0.7 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.2% · Q3 5.4% · Q4 4.5% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
11.2%
5.1 pts worse
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 17.0% · Q3 14.3% · Q4 18.4% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.5% |
20.6%
5.9 pts worse
|
16.7%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 29.0% · Q3 24.6% · Q4 21.9% · 4Q avg 26.5% · 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 | 8.3% |
15.2%
6.9 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.8% · Q3 13.7% · Q4 7.4% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.2% |
14.6%
10.4 pts better
|
14.9%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.7% · Q3 6.0% · Q4 2.4% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.8%
0.5 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 1.5% · Q4 0.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
22.4%
4.8 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 32.5% · Q3 17.2% · Q4 27.9% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
3.7%
1.6 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.4% · Q3 5.4% · Q4 6.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
76.4%
21 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 97.8% · Q3 97.6% · Q4 95.8% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
12.8%
8.2 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 4.7% · Expected 11.4% · 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 | 97.8% |
75.6%
22.2 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
20.3%
0.5 pts worse
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 27.9% · Expected 32.0% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (10 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-24
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 2024-06-07
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-05-24
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Not marked corrected
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-17
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-12
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-26
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-01
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-01
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-01
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-01
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 2025-07-01
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-09
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-09
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-08-09
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-08-09
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-09
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-08-09
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-09
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-04-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-12
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-12
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-12
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-12
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-04-12
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-04-12
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-12
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-12
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-02
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-02
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-02
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-10-02
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-02
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-02
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-09-13
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-01
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 2023-09-01
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 2023-09-01
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-01
Health
Provide activities to meet all resident's needs.
Corrected 2023-05-05
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-05-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-01-14
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-01-14
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-01-14
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-14
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-01-14
Penalties and ownership
Fine · fine $36,569
Fine
Fine · fine $30,729
Fine
Fine · fine $22,640
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Nearby options
Pueblo, CO
4-star overall rating with 4-star inspections with $118,811 in total fines with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Pueblo, CO
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
Pueblo, CO
4-star overall rating with 3-star inspections with $9,575 in total fines with 3 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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