• CMS rates this facility 3/5 stars (average)
• Has 106 certified beds with an average of 84.3 residents per day (80% occupancy)
• Last health inspection found 12 deficiencies (inspected Aug 28, 2025)
• Has been fined a total of $18,769 across 1 fine(s)
• Total nursing staff: 3.17 hours per resident per day
• Staff turnover rate: 36.8%
• Part of the The Ensign Group chain (324 facilities)
Lakeshore Post Acute and Rehabilitation Center is a 3-star Medicare and Medicaid certified nursing home in Pueblo, Colorado with 106 certified beds. It has been operating since 1986. The facility scored at average compared to Colorado facilities.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Provide activities to meet all resident's needs.
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Provide activities to meet all resident's needs.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure medication error rates are not 5 percent or greater.
Ensure that residents are free from significant medication errors.
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.
Provide and implement an infection prevention and control program.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Honor the resident's right to organize and participate in resident/family groups in the facility.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide care by qualified persons according to each resident's written plan of care.
Assist a resident in gaining access to vision and hearing services.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
+ 4 more deficiencies
Staffing hours per resident per day. The black line shows the national average.
Quality measures as percentages of residents. Lower is better for all measures.
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| ENDURA HEALTHCARE LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | May 24, 2024 |
| THE ENSIGN GROUP INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | 100% | May 24, 2024 |
| PRIME TIME HEALTHCARE LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | N/A | Sep 1, 2024 |
| MALONEY, ANN | OPERATIONAL/MANAGERIAL CONTROL | Individual | N/A | Sep 1, 2024 |
| REDDY, VIKAS | OPERATIONAL/MANAGERIAL CONTROL | Individual | N/A | Sep 1, 2024 |
| JORGENSEN, DAVID | CORPORATE DIRECTOR | Individual | N/A | May 24, 2024 |
| BURNAM, SOON | CORPORATE OFFICER | Individual | N/A | May 24, 2024 |
| DUNYON, DAVID | CORPORATE OFFICER | Individual | N/A | May 24, 2024 |
| KEETCH, CHAD | CORPORATE OFFICER | Individual | N/A | Mar 1, 2011 |
| SATO, AMI | CORPORATE OFFICER | Individual | N/A | Sep 9, 2024 |
This chain operates 324 facilities. View all →