Nursing homes › Colorado › Lakeshore Post Acute and Rehabilitation Center
2701 California St, Pueblo, CO 81004 · 7195611300 · 106 certified beds
Per CMS filings, this facility is affiliated with The Ensign Group, a group operating 346 facilities in 17 states. Group record: average rating 3.2/5, 33 abuse citation icons, 9 facilities on the Special Focus list, $7,179,329 in federal fines. This facility rates above its group average (3.2/5).
Total nurse staffing: 3.38 (Colorado median: 3.49). RN hours: 0.73. Weekend total: 2.99. Nursing staff turnover: 44%.
All-time on record: 30 deficiency citations. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2025-08-28 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E | Health | corrected 2025-09-24 |
| 2025-08-28 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D | Health | corrected 2025-09-24 |
| 2025-08-28 | Provide activities to meet all resident's needs. | D | Health | corrected 2025-09-24 |
| 2025-08-28 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Health | corrected 2025-09-24 |
| 2025-08-28 | 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. | D | Health | corrected 2025-09-24 |
| 2025-08-28 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Health | corrected 2025-09-24 |
| 2025-08-28 | Ensure medication error rates are not 5 percent or greater. | D | Health | corrected 2025-09-24 |
| 2025-08-28 | Ensure that residents are free from significant medication errors. | D | Health | corrected 2025-09-24 |
| 2025-08-28 | 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. | D | Health | corrected 2025-09-24 |
| 2025-08-28 | Provide and implement an infection prevention and control program. | D | Health | corrected 2025-09-24 |
| 2025-02-26 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | E | complaint | corrected 2025-04-01 |
| 2025-02-26 | Provide activities to meet all resident's needs. | E | complaint | corrected 2025-04-01 |
| 2023-10-26 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Health | corrected 2023-11-24 |
| 2023-10-26 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E | Health | corrected 2023-11-24 |
| 2023-10-26 | 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. | E | Health | corrected 2023-11-24 |
| 2023-10-26 | 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. | E | Health | corrected 2023-11-24 |
| 2023-10-26 | Provide and implement an infection prevention and control program. | E | Health | corrected 2023-12-13 |
| 2023-10-26 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E | Health | corrected 2023-11-24 |
| 2023-10-26 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Health | corrected 2024-01-23 |
| 2023-10-26 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Health | corrected 2023-11-24 |
| 2023-10-26 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Health | corrected 2023-11-24 |
| 2023-10-26 | Provide care by qualified persons according to each resident's written plan of care. | D | Health | corrected 2023-11-24 |
| 2023-10-26 | Assist a resident in gaining access to vision and hearing services. | D | Health | corrected 2023-12-19 |
| 2023-10-26 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Health | corrected 2023-11-24 |
| 2023-10-26 | Provide safe and appropriate respiratory care for a resident when needed. | D | Health | corrected 2023-12-06 |
| 2023-10-26 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D | Health | corrected 2023-11-24 |
No federal fines or payment denials on record.
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| MALONEY, ANN | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 09/01/2024 |
| REDDY, VIKAS | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 09/01/2024 |
| JORGENSEN, DAVID | Corporate Director | Individual | NOT APPLICABLE | since 05/24/2024 |
| BURNAM, SOON | Corporate Officer | Individual | NOT APPLICABLE | since 05/24/2024 |
| DUNYON, DAVID | Corporate Officer | Individual | NOT APPLICABLE | since 05/24/2024 |
| KEETCH, CHAD | Corporate Officer | Individual | NOT APPLICABLE | since 03/01/2011 |
| SATO, AMI | Corporate Officer | Individual | NOT APPLICABLE | since 09/09/2024 |
| PRIME TIME HEALTHCARE LLC | Operational/Managerial Control | Organization | NOT APPLICABLE | since 09/01/2024 |
| MALONEY, ANN | Operational/Managerial Control | Individual | NOT APPLICABLE | since 09/01/2024 |
| REDDY, VIKAS | Operational/Managerial Control | Individual | NOT APPLICABLE | since 09/01/2024 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 065229. Corrections: data@carerecords.org.