01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-28 | 10 | 2023-10-26 | 15 |
| Cycle 2 | 2023-10-26 | 16 | 2022-07-07 | 15 |
| Cycle 3 | 2022-07-07 | 4 | 2021-04-07 | 10 |
CMS CCN 0652292026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Lakeshore Post Acute And Rehabilitation Center
2701 California St · Pueblo, CO 81004 · Pueblo County
Certified beds106CMS provider file
Recent citation rows70current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
70 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 9 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-08-28 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-08-28 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-08-28 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-08-28 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-08-28 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-08-28 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-08-28 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-08-28 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-08-28 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-08-28 · HEALTHF0921Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2025-09-242025-02-26 · HEALTHF0655Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2025-04-01 · complaint2025-02-26 · HEALTHF0679Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2025-04-01 · complaint2023-10-26 · FIREE0015Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · FIREE0018Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish procedures for tracking staff and patients during an emergency.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · FIREE0023Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for medical documentation.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · FIREE0026Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish roles under a Waiver declared by secretary.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · FIREE0029Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop a communication plan.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · FIREE0031Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide emergency officials' contact information.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · FIREE0033Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish methods for sharing information.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · HEALTHF0565Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-11-242023-10-26 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-01-2303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MALONEY, ANNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 09/01/2024
- REDDY, VIKASIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 09/01/2024
- JORGENSEN, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/24/2024
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/24/2024
- DUNYON, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/24/2024
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- SATO, AMIIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/09/2024
- PRIME TIME HEALTHCARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- MALONEY, ANNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- REDDY, VIKASIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- PORT, BARRYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 06/21/2025
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 09/01/2024
- SMV PUEBLO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 09/01/2024
- MALONEY, ANNIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/21/2025
- REDDY, VIKASIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/01/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.38per resident day
RN hours0.73per resident day
Weekend nurse hours2.99per resident day
Staff turnover44.1%CMS reported field
06 / LOCAL RECORDS
Open the Pueblo ledger →Other published facilities nearby
Atlas Post Acute146 beds · CMS overall 3/552 citation rowsCenter At Park West Llc, The80 beds · CMS overall 2/534 citation rowsHigh Plains Post Acute Llc59 beds · CMS overall 2/535 citation rowsLife Care Center Of Pueblo187 beds · CMS overall 4/554 citation rowsPueblo Heights Nursing And Rehabilitation120 beds · CMS overall 2/539 citation rowsRock Canyon Respiratory And Rehabilitation Center151 beds · CMS overall 1/548 citation rowsUniversity Park Care Center180 beds · CMS overall 4/543 citation rowsVista Ridge Care And Rehabilitation90 beds · CMS overall 3/554 citation rows