Map showing the location of LAKESHORE POST ACUTE AND REHABILITATION CENTER in PUEBLO, Colorado
2701 CALIFORNIA ST, PUEBLO, CO, 81004

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • ColoradoAbove only 41% of peers208 rated homes · average 3.1★
  • Pueblo CountyAbove only 13% of peers9 rated homes · average 3.3★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.7 vs CO avg
  • StaffingCan add or remove a star4★+0.9 vs CO avg
  • Quality measuresCan add or remove a star5★+0.8 vs CO avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 20% of peersCO avg2.7★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 57% of peersCO avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 50% of peersCO avg4.2★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.17hrsAbove only 27% of peersCO avg3.73Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.87hrsAbove 66% of peersCO avg0.83Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better37%Above 79% of peersCO avg49%RN turnover25%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$18,769Above only 40% of peersCO avg$25,587Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
34citations
5inspection dates
2actual harm (G–I)
0immediate jeopardy (J–L)
Aug 28, 2025most recent

Citations by monthJul 2022 – Aug 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Aug 28, 202510 citationsCycle 1worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 24, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 24, 2025
  3. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Sep 24, 2025
  4. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Sep 24, 2025
  5. F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsD · isolatedCorrected Sep 24, 2025
  6. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Sep 24, 2025
  7. F688Provide 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.Quality of Life and CareD · isolatedCorrected Sep 24, 2025
  8. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 24, 2025
  9. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Sep 24, 2025
  10. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Sep 24, 2025
Feb 26, 20252 citationsCycle 1worst E · no actual harm
  1. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected Apr 1, 2025
  2. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Apr 1, 2025
Oct 26, 202314 citationsCycle 2worst F · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 24, 2023
  2. F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Nov 24, 2023
  3. F584Honor 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.Resident RightsE · patternCorrected Nov 24, 2023
  4. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 23, 2024
  5. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 24, 2023
  6. F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Dec 19, 2023
  7. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 24, 2023
  8. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Dec 6, 2023
  9. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareD · isolatedCorrected Nov 24, 2023
  10. F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Pharmacy ServiceE · patternCorrected Nov 24, 2023
  11. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Nov 24, 2023
  12. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 13, 2023
  13. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesE · patternCorrected Nov 24, 2023
  14. F282Provide care by qualified persons according to each resident's written plan of care.Resident Assessment and Care PlanningD · isolatedCorrected Nov 24, 2023
Mar 9, 20234 citationsCycle 3worst G · actual harm$18,769
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Apr 6, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Apr 6, 2023
  3. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Apr 6, 2023
  4. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 6, 2023
Jul 7, 20224 citationsCycle 3worst D · no actual harm
  1. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jul 30, 2022
  2. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Jul 30, 2022
  3. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jul 30, 2022
  4. Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Jul 30, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.17hrsAbove only 27% of peers−0.56 vs CO avg
  • Registered nursesRN hours only0.87hrsAbove 66% of peers+0.04 vs CO avg
  • Licensed practical nursesLPN hours0.36hrs
  • Nurse aidesCNA hours1.94hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.79hrs
  • Colorado average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better37%Above 79% of peersCO avg 49%
  • RN turnoverRegistered nurses only25%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy106 certified beds · ~84 residents a day80%Above only 40% of peersCO avg 79%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $18,769In fines
  • 1Fine
  • 0Payment denials
  • $25,587CO avg in fines
Above only 40% of peersFewer fines than 40% of rated homes in Colorado

Actions on record

  1. Mar 9, 2023Civil money penalty$18,769

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
The Ensign Group324 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Endura Healthcare LLC
Indirect owners (5%+)
  • The Ensign Group INC
Operational or managerial control
  • Prime Time Healthcare LLC
  • Ann Maloney
  • Vikas Reddy
Corporate directors
  • David Jorgensen
Corporate officers
  • Soon Burnam
  • David Dunyon
  • Chad Keetch
  • Ami Sato

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 065229 · 2701 CALIFORNIA ST, PUEBLO, CO, 81004.
  • Percentiles compare this facility with every rated nursing home in Colorado and Pueblo County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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