Lakeshore Post Acute and Rehabilitation Center

Name: Lakeshore Post Acute and Rehabilitation Center
Address: 2701 CALIFORNIA ST, Pueblo, CO, 81004, US
Telephone: 7195611300

2701 California St, Pueblo, CO 81004 · Pueblo County · 106 certified beds · avg 81 residents/day · certified since Apr 1, 1986

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.38

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (30)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Aug 28, 2025	E · Potential for harm, repeated	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Aug 28, 2025	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Aug 28, 2025	D · Potential for harm, one-off	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Aug 28, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Aug 28, 2025	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Aug 28, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Aug 28, 2025	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Aug 28, 2025	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Aug 28, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Aug 28, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 26, 2025	E · Potential for harm, repeated	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint
Feb 26, 2025	E · Potential for harm, repeated	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint
Oct 26, 2023	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 26, 2023	E · Potential for harm, repeated	The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Oct 26, 2023	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Oct 26, 2023	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Oct 26, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Oct 26, 2023	E · Potential for harm, repeated	The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.
Oct 26, 2023	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Oct 26, 2023	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Oct 26, 2023	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Oct 26, 2023	D · Potential for harm, one-off	The facility did not make sure care was delivered by qualified people following each resident's written care plan — the individualized document that spells out exactly what care that resident is supposed to receive.
Oct 26, 2023	D · Potential for harm, one-off	The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Oct 26, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 26, 2023	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Oct 26, 2023	D · Potential for harm, one-off	The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
Jul 7, 2022	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jul 7, 2022	D · Potential for harm, one-off	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Jul 7, 2022	D · Potential for harm, one-off	The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Jul 7, 2022	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (14 → 10).

Year	Citations	Worst severity that year
2022	4	D
2023	14	F
2025	12	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Colorado avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.38	3.89	3.95	bottom 28% in Colorado; bottom 30% in the U.S.
Registered Nurse hours	0.73	0.86	0.69	bottom 42% in Colorado; top 33% in the U.S.
Weekend total nurse staffing	2.99	3.44	3.50	bottom 29% in Colorado; bottom 30% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.49	0.61	0.48	bottom 42% in Colorado; top 33% in the U.S.
Total nursing staff turnover (%)	44.1	47.1	45.8	top 41% in Colorado; top 48% in the U.S.
RN turnover (%)	37.5	44.6	42.9	top 34% in Colorado; top 42% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.38, RN 0.73, weekend 2.99. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	05/24/2024
Dunyon, David	Individual	Corporate Officer	NOT APPLICABLE	05/24/2024
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	09/01/2024
Jorgensen, David	Individual	Corporate Director	NOT APPLICABLE	05/24/2024
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Maloney, Ann	Individual	Managing Control - Governing Body	NOT APPLICABLE	09/01/2024
Maloney, Ann	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2024
Maloney, Ann	Individual	ADP of the SNF	NOT APPLICABLE	06/21/2025
Port, Barry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	06/21/2025
Prime Time Healthcare LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	09/01/2024
Reddy, Vikas	Individual	Managing Control - Governing Body	NOT APPLICABLE	09/01/2024
Reddy, Vikas	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2024
Reddy, Vikas	Individual	ADP of the SNF	NOT APPLICABLE	09/01/2024
Sato, Ami	Individual	Corporate Officer	NOT APPLICABLE	09/09/2024
SMV Pueblo LLC	Organization	ADP of the SNF	NOT APPLICABLE	09/01/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"What systems do you use to prevent medication errors, and what happens when one occurs?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Atlas Post Acute	1.1 mi	Pueblo, CO	★★★☆☆	4/5
Rock Canyon Respiratory and Rehabilitation Center	1.3 mi	Pueblo, CO	★☆☆☆☆	2/5	abuse
Life Care Center of Pueblo	2.2 mi	Pueblo, CO	★★★★☆	3/5
High Plains Post Acute LLC	3.2 mi	Pueblo, CO	★★☆☆☆	2/5
Vista Ridge Care and Rehabilitation	4.8 mi	Pueblo, CO	★★★☆☆	3/5
Pueblo Heights Nursing and Rehabilitation	5.2 mi	Pueblo, CO	★★☆☆☆	2/5
University Park Care Center	6.3 mi	Pueblo, CO	★★★★☆	3/5
Center at Park West LLC, the	6.3 mi	Pueblo, CO	★★☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Pueblo →

Facility data as of CMS processing date 2026-08-01. CCN 065229.

The Care File

Visit checklist — Lakeshore Post Acute and Rehabilitation Center

2701 California St, Pueblo, CO 81004 · 7195611300

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 065229 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)