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Public Record

Lakeshore Post Acute and Rehabilitation Center

Nursing HomePueblo, COCMS 065229
74 citations on record

From CMS

Facility profile

CMS overall rating
4 / 5

*CMS Five-Star

Certified beds
106

*CMS

Avg. residents per day
79.1

*CMS

Inspection record

On record from CMS

Citations on record
74

*CMS

Inspections on file
8

*CMS

Last inspection
2025-08-28

*CMS

Citations

74 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0760Generalpotential for harm

    Ensure that residents are free from significant medication errors.

  • 0688Generalpotential for harm

    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.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0921Generalpotential for harm

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  • 0761Generalpotential for harm

    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.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0628Generalpotential for harm

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  • 0679Generalpotential for harm

    Provide activities to meet all resident's needs.

  • 0655Generalpotential for harm

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  • 0679Generalpotential for harm

    Provide activities to meet all resident's needs.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0695Generalpotential for harm

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0758Generalpotential for harm

    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.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0947Generalpotential for harm

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  • 0565Generalpotential for harm

    Honor the resident's right to organize and participate in resident/family groups in the facility.

  • 0584Generalpotential for harm

    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.

  • 0604Generalpotential for harm

    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  • 0744Generalpotential for harm

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  • 0346Generalpotential for harm

    Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0291Generalpotential for harm

    Install emergency lighting that can last at least 1 1/2 hours.

  • 0222Generalpotential for harm

    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  • 0039Generalpotential for harm

    Conduct testing and exercise requirements.

  • 0036Generalpotential for harm

    Establish emergency prep training and testing.

  • 0033Generalpotential for harm

    Establish methods for sharing information.

  • 0031Generalpotential for harm

    Provide emergency officials' contact information.

  • 0029Generalpotential for harm

    Develop a communication plan.

  • 0026Generalpotential for harm

    Establish roles under a Waiver declared by secretary.

  • 0018Generalpotential for harm

    Establish procedures for tracking staff and patients during an emergency.

  • 0023Generalpotential for harm

    Establish policies and procedures for medical documentation.

  • 0015Generalpotential for harm

    Address subsistence needs for staff and patients.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0914Generalpotential for harm

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  • 0521Generalpotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0354Generalpotential for harm

    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0609Generalpotential for harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0659Generalpotential for harm

    Provide care by qualified persons according to each resident's written plan of care.

  • 0685Generalpotential for harm

    Assist a resident in gaining access to vision and hearing services.

  • 0686Seriousactual harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0692Seriousactual harm

    Provide enough food/fluids to maintain a resident's health.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0623Generalpotential for harm

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0558Generalpotential for harm

    Reasonably accommodate the needs and preferences of each resident.

  • 0741Generalpotential for harm

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0355Generalpotential for harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0226Generalpotential for harm

    Have horizontal exits used in accordance with safety requirements.

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0521Generalpotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0625Generalpotential for harm

    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.

  • 0919Generalpotential for harm

    Meet requirements for the use of electrical equipment.

  • 0521Generalpotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0325Generalpotential for harm

    Have properly installed hallway dispensers for alcohol-based hand rub.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0227Generalpotential for harm

    Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0912Generalpotential for harm

    Have power receptacles that are properly grounded.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

FAQ

Questions and answers

What is Lakeshore Post Acute and Rehabilitation Center?
Lakeshore Post Acute and Rehabilitation Center is a Medicare- and Medicaid-certified nursing home in Pueblo, CO, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 065229.
What is the CMS rating for Lakeshore Post Acute and Rehabilitation Center?
Lakeshore Post Acute and Rehabilitation Center has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Lakeshore Post Acute and Rehabilitation Center have?
Lakeshore Post Acute and Rehabilitation Center is certified for 106 beds. It serves an average of 79.1 residents per day.
How many citations does Lakeshore Post Acute and Rehabilitation Center have?
Lakeshore Post Acute and Rehabilitation Center has 74 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Lakeshore Post Acute and Rehabilitation Center last inspected?
Lakeshore Post Acute and Rehabilitation Center was last inspected on August 28, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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