LAKESHORE POST ACUTE AND REHABILITATION CENTER
2701 CALIFORNIA ST, PUEBLO, CO 81004 · CCN 065229
Ratings
- Overall
- ★★★☆☆ 3
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★★ 5
- Staffing
- ★★★★☆ 4
Facility
- Ownership type
- For profit - Corporation
- Certified beds
- 106
- Avg residents/day
- 84.3
- Phone
- 7195611300
Inspection history vs Colorado & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Colorado avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-08-28 | 10 | 8.7 | 9.5 | +1.3 worse |
| 2 | 2023-10-26 | 16 | 8.7 | 9.8 | +7.3 worse |
| 3 | 2022-07-07 | 8 | 7.5 | 9.3 | +0.5 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 4 |
| Resident rights | 1 |
| Pharmacy service | 3 |
| Environmental | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.17 | 36.8% |
| RN staffing (reported) | 0.87 | 25.0% |
| Total nurse staffing (adjusted) | 3.45 | — |
Fines & penalties
- Total fines
- $0
- Number of fines
- 0
- Number of penalties
- 0
- Payment denials
- 0
Chain
- Chain
- THE ENSIGN GROUP
- Facilities in chain
- 329
- Chain avg overall
- 3.20 / 5
Inspection citations (34)2 actual harm
- DF0628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.2025-08-28 · Health · corrected 2025-09-24
Potential for more than minimal harm
- DF0679Provide activities to meet all resident's needs.2025-08-28 · Health · corrected 2025-09-24
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-08-28 · Health · corrected 2025-09-24
Potential for more than minimal harm
- DF0688Provide 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.2025-08-28 · Health · corrected 2025-09-24
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-08-28 · Health · corrected 2025-09-24
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2025-08-28 · Health · corrected 2025-09-24
Potential for more than minimal harm
- DF0760Ensure that residents are free from significant medication errors.2025-08-28 · Health · corrected 2025-09-24
Potential for more than minimal harm
- DF0761Ensure 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.2025-08-28 · Health · corrected 2025-09-24
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2025-08-28 · Health · corrected 2025-09-24
Potential for more than minimal harm
- EF0921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.2025-08-28 · Health · corrected 2025-09-24
Potential for more than minimal harm
- EF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2025-02-26 · Health · corrected 2025-04-01
Potential for more than minimal harm
- EF0679Provide activities to meet all resident's needs.2025-02-26 · Health · corrected 2025-04-01
Potential for more than minimal harm
- EF0565Honor the resident's right to organize and participate in resident/family groups in the facility.2023-10-26 · Health · corrected 2023-11-24
Potential for more than minimal harm
- EF0584Honor 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.2023-10-26 · Health · corrected 2023-11-24
Potential for more than minimal harm
- DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-10-26 · Health · corrected 2024-01-23
Potential for more than minimal harm
- DF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2023-10-26 · Health · corrected 2023-11-24
Potential for more than minimal harm
- DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2023-10-26 · Health · corrected 2023-11-24
Potential for more than minimal harm
- DF0659Provide care by qualified persons according to each resident's written plan of care.2023-10-26 · Health · corrected 2023-11-24
Potential for more than minimal harm
- DF0685Assist a resident in gaining access to vision and hearing services.2023-10-26 · Health · corrected 2023-12-19
Potential for more than minimal harm
- DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-10-26 · Health · corrected 2023-11-24
Potential for more than minimal harm
- DF0695Provide safe and appropriate respiratory care for a resident when needed.2023-10-26 · Health · corrected 2023-12-06
Potential for more than minimal harm
- DF0744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.2023-10-26 · Health · corrected 2023-11-24
Potential for more than minimal harm
- EF0758Implement 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.2023-10-26 · Health · corrected 2023-11-24
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-10-26 · Health · corrected 2023-11-24
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2023-10-26 · Health · corrected 2023-12-13
Potential for more than minimal harm
- EF0947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.2023-10-26 · Health · corrected 2023-11-24
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2023-03-09 · Health · corrected 2023-04-06
Potential for more than minimal harm
- GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2023-03-09 · Health · corrected 2023-04-06
Actual harm
- EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-03-09 · Health · corrected 2023-04-06
Potential for more than minimal harm
- GF0692Provide enough food/fluids to maintain a resident's health.2023-03-09 · Health · corrected 2023-04-06
Actual harm
- DF0558Reasonably accommodate the needs and preferences of each resident.2022-07-07 · Health · corrected 2022-07-30
Potential for more than minimal harm
- DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2022-07-07 · Health · corrected 2022-07-30
Potential for more than minimal harm
- DF0625Notify 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.2022-07-07 · Health · corrected 2022-07-30
Potential for more than minimal harm
- DF0759Ensure medication error rates are not 5 percent or greater.2022-07-07 · Health · corrected 2022-07-30
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| THE ENSIGN GROUP INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | 2024-05-24 |
| ENDURA HEALTHCARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2024-05-24 |
| MALONEY, ANN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 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 |
| REDDY, VIKAS | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-09-01 |
| SATO, AMI | Individual | CORPORATE OFFICER | — | 2024-09-09 |
| PRIME TIME HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-09-01 |
Other facilities in PUEBLO
| Name | Overall | Beds |
|---|---|---|
| CENTER AT PARK WEST LLC, THE | ★★★★☆ | 80 |
| ATLAS POST ACUTE | ★★★★☆ | 146 |
| University Park Care Center | ★★★★☆ | 180 |
| LIFE CARE CENTER OF PUEBLO | ★★★★☆ | 187 |
| Pueblo Heights Nursing and Rehabilitation | ★★★★☆ | 120 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.