Pueblo, CO

Life Care Center Of Pueblo

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

2118 Chatalet Ln, Pueblo, CO

(719) 564-2000

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

187

Certified beds

Average residents

113

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Life Care Centers Of America

Operator or chain grouping

Approved since

1989-11-21

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

194 facilities

Chain averages 4 overall / 3 health / 3 staffing / 5 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

Hours and turnover

RN hours / resident day

1.09

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.50

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

2.11

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.70

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.59

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

3.15

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.77

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

1.10

CMS adjusted RN staffing hours

Adjusted total hours

3.75

CMS adjusted total nurse staffing hours

Case-mix index

1.35

Higher values indicate more complex resident acuity

RN turnover

47%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

46%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,474

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

56.46

Composite VBP score used to determine payment impact.

Payment multiplier

1.0116

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

8.93

Baseline 18.95% · Performance 17.29% · Measure score 8.93 · Achievement 8.93 · Improvement 8.12

Healthcare-associated infections

4.08

Baseline 5.97% · Performance 6.61% · Measure score 4.08 · Achievement 4.08 · Improvement 0

Total nurse turnover

7.25

Baseline 48.57% · Performance 34.07% · Measure score 7.25 · Achievement 7.25 · Improvement 5.62

Adjusted total nurse staffing

2.33

Baseline 3.25 hours · Performance 3.74 hours · Measure score 2.33 · Achievement 2.33 · Improvement 1.44

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.34%
10.72%
1.4 pts better
No Different than the National Rate · Eligible stays 96 · Observed rate 6.25% · Lower 95% interval 6.16%
Discharge to community 65.54%
50.57%
15 pts better
Better than the National Rate · Eligible stays 93 · Observed rate 60.22% · Lower 95% interval 55.75%
Medicare spending per beneficiary 0.94
1.02
0.1 pts better
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 51 · Denominator 51
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 51
Discharge self-care score 75%
53.69%
21.3 pts better
Numerator 27 · Denominator 36
Discharge mobility score 55.56%
50.94%
4.6 pts better
Numerator 20 · Denominator 36
Pressure ulcers or injuries, new or worsened 1.96%
2.29%
0.3 pts better
Numerator 1 · Denominator 51 · Adjusted rate 2.1%
Healthcare-associated infections requiring hospitalization 6.61%
7.12%
0.5 pts better
No Different than the National Rate · Eligible stays 58 · Observed rate 5.17% · Lower 95% interval 3.48%
Staff COVID-19 vaccination coverage 9.89%
8.2%
1.7 pts better
Numerator 18 · Denominator 182
Staff flu vaccination coverage 59.61%
42%
17.6 pts better
Numerator 152 · Denominator 255
Discharge function score 69.44%
56.45%
13 pts better
Numerator 25 · Denominator 36
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 21 · Denominator 21
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 4.17%
25.2%
21 pts worse
Numerator 1 · Denominator 24

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.4
1.3
0.1 pts worse
1.9
0.5 pts better
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.5
1.7
1.2 pts better
1.8
1.3 pts better
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 96.9%
93.5%
3.4 pts better
93.4%
3.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 96.8% · Q3 96.0% · Q4 97.0% · 4Q avg 96.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 92.2%
94.7%
2.5 pts worse
95.5%
3.3 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2%
Percentage of long-stay residents experiencing one or more falls with major injury 1.8%
3.4%
1.6 pts better
3.3%
1.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.2% · Q3 1.0% · Q4 2.0% · 4Q avg 1.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 7.9%
7.4%
0.5 pts worse
11.4%
3.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 11.2% · Q3 7.1% · Q4 6.0% · 4Q avg 7.9%
Percentage of long-stay residents who lose too much weight 4.4%
5.0%
0.6 pts better
5.4%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.9% · Q3 5.7% · Q4 3.5% · 4Q avg 4.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 10.9%
11.2%
0.3 pts better
19.6%
8.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 11.5% · Q3 11.4% · Q4 10.2% · 4Q avg 10.9%
Percentage of long-stay residents who received an antipsychotic medication 14.3%
20.6%
6.3 pts better
16.7%
2.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 14.3% · Q3 12.5% · Q4 13.7% · 4Q avg 14.3% · 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 28.8%
15.2%
13.6 pts worse
16.3%
12.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 35.1% · Q3 17.0% · Q4 25.3% · 4Q avg 28.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 16.2%
14.6%
1.6 pts worse
14.9%
1.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 18.3% · Q3 14.3% · Q4 13.3% · 4Q avg 16.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.2%
0.8%
0.6 pts better
1.0%
0.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 1.6%
1.5%
0.1 pts worse
1.7%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 2.0% · Q4 2.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 30.0%
22.4%
7.6 pts worse
19.8%
10.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 32.5% · Q3 21.6% · Q4 29.5% · 4Q avg 30.0%
Percentage of long-stay residents with pressure ulcers 6.5%
3.7%
2.8 pts worse
5.1%
1.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.6% · Q3 4.8% · Q4 4.1% · 4Q avg 6.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 91.8%
76.4%
15.4 pts better
81.7%
10.1 pts better
Short Stay · 2024Q4-2025Q3 · Q1 86.6% · Q2 91.5% · Q3 91.8% · Q4 97.1% · 4Q avg 91.8%
Percentage of short-stay residents who had an outpatient emergency department visit 13.0%
12.8%
0.2 pts worse
12.0%
1 pts worse
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 12.8% · Expected 11.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.6%
1.5%
0.1 pts worse
1.6%
About the same
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 2.8% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 90.8%
75.6%
15.2 pts better
79.7%
11.1 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 22.0%
20.3%
1.7 pts worse
23.9%
1.9 pts better
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 23.1% · Expected 25.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-09 · Fire 2024-05-09

3 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

12 fire-safety deficiencies

Top issue: Egress (4 deficiencies)

Cycle 2 Health 2020-01-30 · Fire 2020-01-30

17 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-01-10 · Fire 2019-01-10

9 health deficiencies

Top issue: Resident Rights (5 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-05-09

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-05-31

F · Potential for more than minimal harm 2024-05-09

K200 · Egress Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-07-04

F · Potential for more than minimal harm 2024-05-09

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-07-04

F · Potential for more than minimal harm 2024-05-09

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-06-09

F · Potential for more than minimal harm 2024-05-09

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-07-04

F · Potential for more than minimal harm 2024-05-09

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-06-14

F · Potential for more than minimal harm 2024-05-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-07-07

F · Potential for more than minimal harm 2024-05-09

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-07-04

F · Potential for more than minimal harm 2024-05-09

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-06-21

F · Potential for more than minimal harm 2024-05-09

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-06-16

F · Potential for more than minimal harm 2024-05-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-06-25

F · Potential for more than minimal harm 2024-05-09

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-06-21

F · Potential for more than minimal harm 2020-01-30

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2020-02-27

F · Potential for more than minimal harm 2020-01-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-02-26

F · Potential for more than minimal harm 2020-01-30

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2020-02-21

F · Potential for more than minimal harm 2020-01-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2020-02-24

D · Potential for more than minimal harm 2020-01-30

K222 · Egress Deficiencies

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 2020-02-21

D · Potential for more than minimal harm 2020-01-30

K321 · Smoke Deficiencies

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 2020-02-18

D · Potential for more than minimal harm 2020-01-30

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2020-02-22

D · Potential for more than minimal harm 2020-01-30

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2020-02-25

D · Potential for more than minimal harm 2020-01-30

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2020-02-13

D · Potential for more than minimal harm 2019-01-10

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-03-08

D · Potential for more than minimal harm 2019-01-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-03-08

Inspection history

Recent health citations

G · Actual harm 2024-08-07

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-08-28

G · Actual harm 2024-08-07

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-08-28

D · Potential for more than minimal harm 2024-08-07

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-08-27

D · Potential for more than minimal harm 2024-08-07

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2024-08-27

D · Potential for more than minimal harm 2024-08-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-08-27

E · Potential for more than minimal harm 2024-05-09

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-06-21

D · Potential for more than minimal harm 2024-05-09

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-09

F761 · Pharmacy Service Deficiencies

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 2024-05-31

G · Actual harm 2020-01-30

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2020-02-24

G · Actual harm 2020-01-30

F865 · Administration Deficiencies

Health

Have a plan that describes the process for conducting QAPI and QAA activities.

Corrected 2020-02-24

F · Potential for more than minimal harm 2020-01-30

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2020-02-24

E · Potential for more than minimal harm 2020-01-30

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2020-02-24

E · Potential for more than minimal harm 2020-01-30

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2020-02-24

E · Potential for more than minimal harm 2020-01-30

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2020-02-24

E · Potential for more than minimal harm 2020-01-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2020-02-24

D · Potential for more than minimal harm 2020-01-30

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2020-02-24

D · Potential for more than minimal harm 2020-01-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2020-02-24

D · Potential for more than minimal harm 2020-01-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2020-02-24

D · Potential for more than minimal harm 2020-01-30

F688 · Quality of Life and Care Deficiencies

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 2020-02-24

D · Potential for more than minimal harm 2020-01-30

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2020-02-24

F · Potential for more than minimal harm 2019-01-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-02-08

E · Potential for more than minimal harm 2019-01-10

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2019-02-08

E · Potential for more than minimal harm 2019-01-10

F584 · Resident Rights Deficiencies

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 2019-02-08

E · Potential for more than minimal harm 2019-01-10

F741 · Quality of Life and Care Deficiencies

Health

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Corrected 2019-02-14

D · Potential for more than minimal harm 2019-01-10

F585 · Resident Rights Deficiencies

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 2019-02-08

D · Potential for more than minimal harm 2019-01-10

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2019-02-08

D · Potential for more than minimal harm 2019-01-10

F625 · Resident Rights Deficiencies

Health

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.

Corrected 2019-02-08

D · Potential for more than minimal harm 2019-01-10

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2019-02-08

D · Potential for more than minimal harm 2019-01-10

F758 · Pharmacy Service Deficiencies

Health

Implement 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.

Corrected 2019-02-08

Penalties and ownership

What sits behind the stars

$9,575 2024-08-07

Fine

Fine · fine $9,575

Fine

Ownership

Preston, Forrest

5% Or Greater Direct Ownership Interest · Individual

99% 188 facilities 1988-02-01
Cross, Cindy

Corporate Officer · Individual

0% 181 facilities 1994-02-03
Life Care Centers Of America, Inc.

Operational/Managerial Control · Organization

0% 194 facilities 1989-09-20
Newman, Roberto

W-2 Managing Employee · Individual

0% 2 facilities 2016-07-18
Thurmond, Joan

Corporate Officer · Individual

0% 191 facilities 2000-09-21

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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

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Staffing
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#2

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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

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Staffing
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Fines
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#3

Lakeshore Post Acute And Rehabilitation Center

Pueblo, CO

3-star overall rating with 2-star inspections with 10 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle

Overall
3 / 5
Health
2 / 5
Staffing
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Fines
$0

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