Lakeshore Post Acute And Rehabilitation Center, Pueblo, CO
Pueblo, Pueblo County, Colorado · CCN 065229 (CMS’s record) · For-profit (Corporation) · part of The Ensign Group (342 facilities, chain average 3.2 stars)
CMS rates Lakeshore Post Acute And Rehabilitation Center 4 of 5 overall as of August 2026. 106 certified beds, 81 residents a day on average. 30 citations on record from the current inspection cycles; no fines on record. Last standard health inspection 2025-08-28.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead. The averages are of CMS’s ratings across the rated homes in the state and the country, from the same file.
| Overall | ★★★★☆ 4 of 5 Colorado average 3.1; national 3.0 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 5 / 4 of 5 |
Staffing
| Total nurse staffing | 3.38 hours per resident per day Colorado average 3.72; national 3.86 |
|---|---|
| Registered nurses | 0.73 hours per resident per day |
| Weekend total | 2.99 hours per resident per day |
| Nursing staff turnover | 44.1% (registered nurses 37.5%) Colorado average 47.1%; national 45.8% |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | 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. Environmental Deficiencies · tag F0921 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-09-24 |
| 2025-08-28 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · tag F0628 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-24 |
| 2025-08-28 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-24 |
| 2025-08-28 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-24 |
| 2025-08-28 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-24 |
| 2025-08-28 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-24 |
| 2025-08-28 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0761 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-24 |
| 2025-08-28 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-24 |
| 2025-02-26 complaint survey |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-01 |
| 2025-02-26 complaint survey |
Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-11-24 |
| 2023-10-26 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · tag F0565 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0758 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-24 |
| 2023-10-26 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Nursing and Physician Services Deficiencies · tag F0947 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-23 |
| 2023-10-26 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-24 |
| 2023-10-26 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-24 |
| 2023-10-26 | Provide care by qualified persons according to each resident's written plan of care. Resident Assessment and Care Planning Deficiencies · tag F0659 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-24 |
| 2023-10-26 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · tag F0685 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-19 |
| 2023-10-26 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-24 |
| 2023-10-26 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-12-06 |
| 2023-10-26 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · tag F0744 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-24 |
| 2022-07-07 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-30 |
| 2022-07-07 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · tag F0623 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-30 |
| 2022-07-07 | 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 Rights Deficiencies · tag F0625 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-30 |
| 2022-07-07 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-07-30 |
Fines and payment denials
No fines or payment denials on record since 2023.
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Ensign Services Inc. Organization | adp of the snf | — | 2024-09-01 |
| Smv Pueblo LLC Organization | adp of the snf | — | 2024-09-01 |
| Prime Time Healthcare LLC Organization | operational/managerial control | — | 2024-09-01 |
| Maloney, Ann Individual | adp of the snf | — | 2025-06-21 |
| Reddy, Vikas Individual | adp of the snf | — | 2024-09-01 |
| Jorgensen, David Individual | corporate director | — | 2024-05-24 |
| Burnam, Soon Individual | corporate officer | — | 2024-05-24 |
| Dunyon, David Individual | corporate officer | — | 2024-05-24 |
| Keetch, Chad Individual | corporate officer | — | 2011-03-01 |
| Sato, Ami Individual | corporate officer | — | 2024-09-09 |
| Port, Barry Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-06-21 |
| Maloney, Ann Individual | managing control - governing body | — | 2024-09-01 |
| Reddy, Vikas Individual | managing control - governing body | — | 2024-09-01 |
| Maloney, Ann Individual | operational/managerial control | — | 2024-09-01 |
| Reddy, Vikas Individual | operational/managerial control | — | 2024-09-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Other nursing homes in Pueblo County
Same city first, then in CMS’s rating order; the order is CMS’s and nothing of ours.
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Pueblo, CO · ★★★☆☆ 3 of 5 - Center At Park West LLC, The
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Pueblo, CO · ★★☆☆☆ 2 of 5 - Rock Canyon Respiratory And Rehabilitation Center
Pueblo, CO · ★☆☆☆☆ 1 of 5
Every nursing home in Pueblo County
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Lakeshore Post Acute And Rehabilitation Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Verify this record yourself on CMS’s Care Compare page for this facility.