Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeshore Post Acute And Rehabilitation Center during CMS and state inspections, most recent first.
Unsafe and Poorly Maintained Resident Areas: The facility failed to maintain resident rooms, shower rooms, and hallways in a safe, functional, sanitary, and comfortable condition. Surveyors observed a missing vent and nonworking ventilation in a shower room, rusty vents, holes in drywall and the ceiling, roof leakage near the dining room entrance, a loose handrail, a hanging hallway light, and multiple resident room doors that were difficult to open. A resident reported water pooling from the ceiling at the entrance, and residents in D6 reported ongoing door problems that had not been fixed.
Failure to Notify Ombudsman in Writing Before Discharge: A resident with a recent lower-leg fracture, asthma, DM2, and fibromyalgia was discharged after a skilled rehab stay, and staff assisted with an appeal after the insurer stopped covering services. However, the SSD only left a voicemail to the LTC ombudsman and did not document written notification before discharge, and the EMR lacked evidence that the ombudsman was notified in writing.
Group Activities Not Provided to Wheelchair-Dependent Residents: Two cognitively intact residents with documented preferences for outings and group activities were often unable to join community trips because the facility bus had only one wheelchair space and they could not transfer to a seat. One resident participated in only a few outside trips over the review period, while the other reported she had not been able to go on a community outing with friends that year. Staff confirmed that residents in wheelchairs were often left behind due to the bus limitation.
A resident with COPD, obesity hypoventilation, respiratory failure, and sleep apnea reported waiting months for a CPAP machine after telehealth pulmonology visits. The chart lacked pulmonology progress notes, a CPAP order, and a care plan focus for CPAP, while staff interviews showed the appointments were not effectively tracked and it was unclear whether a sleep study had ever been scheduled.
The facility failed to provide ordered contracture care for two residents. One resident with a right hand contracture was repeatedly observed without the ordered wrist splint or palm protector even though the TAR showed it as applied, and there was no progress note documenting refusal or application. Another resident with bilateral ankle contractures and MS was supposed to receive restorative PROM and boot support, but observations showed no PROM provided during a continuous observation and the EMR lacked documentation of restorative sessions.
A resident with dementia, severe cognitive impairment, and a wander guard had a history of exit-seeking and required supervision while smoking, but was observed self-propelling out to the smoking patio without staff present on more than one occasion. The wander guard alarm did not activate during one exit, and the smoking area had an unsecured gate leading directly to the street. Staff interviews confirmed the resident needed supervision whenever outside the building, yet he was left unsupervised in the smoking area.
Medication administration errors exceeded the allowed rate, with three errors found in 29 opportunities. An LPN failed to ensure a resident took the full ordered dose of a Symbicort inhaler and did not instruct the resident to rinse and spit afterward, an RN allowed another resident to use a Dulera inhaler without rinsing and spitting afterward, and an RN administered Lantus insulin without priming the pen before both parts of the dose and initially gave less than the ordered amount.
Insulin pen not primed before administration. An RN administered insulin to a cognitively intact resident with DM using an insulin pen, but failed to prime the pen before giving 13 units and again failed to prime it before giving the remaining 2 units after realizing the ordered dose was 15 units. The RN said she was not clear on the correct priming process, while the pharmacy consultant and DON stated the needle must be attached and the pen primed before insulin is given so the resident receives the full dose.
Medication storage and labeling were not maintained properly in two med carts and one med storage room. Unsecured bubble packs for two discharged residents were left on a counter in the med room, and several medications in labeled med boxes were missing the resident name and open date on the individual containers, including nasal spray bottles and a semaglutide tablet. The RCR said discharged residents' meds should have been taken to the DON's office and stated she did not know the containers needed labels inside the boxes.
Infection Control Lapses During Medication Administration: An RN failed to disinfect a resident’s glucometer per manufacturer directions, spending less than 10 seconds wiping the device and not keeping the surface visibly wet for the required contact time. The same RN also failed to remove gloves and perform hand hygiene before leaving a resident’s room during med pass, then used the same gloved hands to get ice and water before continuing oral medication administration.
The facility failed to implement baseline care plans within 48 hours of admission for three residents, omitting critical medical information necessary for effective care. A resident with schizophrenia and bipolar disorder did not have required specialized services included in their care plan. Another resident with end-stage renal failure lacked dietary restrictions and hemodialysis details in their plan, while an elderly resident's need for a diabetic diet and oxygen was also omitted.
The facility failed to provide personalized activity programs for residents, leading to a lack of engagement and meaningful interaction. A resident with Alzheimer's was not assisted to attend important religious services, while another with dementia was often left idle or watching TV. A third resident with severe cognitive impairments was not offered preferred activities like music or outdoor time. The activity calendar lacked variety, and one-on-one programs were insufficiently implemented.
Unsafe and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public because resident rooms, shower rooms, and hallways were not properly maintained and repaired. Observations showed a missing vent in the A hall shower room that left a hole in the ceiling, the ventilation system in that shower room was not working, vents on the A and B halls were rusty with a brown substance and missing paint, a hole was present in the drywall of room F-4, and room [ROOM NUMBER] on C hall had water leaking from the ceiling ventilation system toward the window. Near the main dining room entrance, water was leaking from the roof, and Resident #1 reported that water had pooled from the ceiling the night before and settled on the ground at the facility entrance. Additional observations found a loose handrail, a light hanging from the hallway ceiling, and multiple resident room doors that were difficult to open, including rooms A2, C12, C13, C16, C18, D3, D5, D6, D7, E6, E10, F1, and F10. Residents in room D6-2 and room [ROOM NUMBER] reported that their doors were difficult to open and close, with one resident stating the door got stuck daily and another stating the issue had not been fixed despite reporting it to CNAs. Two residents in room D6 said one roommate stayed in the room most of the time because the other roommate could not open the door when returning. The maintenance director and NHA acknowledged the identified concerns during the environmental tour and interviews, and the maintenance director stated the roof was being replaced and that the facility used an electronic work order system.
Failure to Notify Ombudsman in Writing Before Discharge
Penalty
Summary
The facility failed to provide and document sufficient discharge preparation and documentation for one resident who was discharged home after a skilled nursing and rehabilitation stay following a fall at home. The resident was cognitively intact with a BIMS score of 14 out of 15 and required assistance with eating, personal hygiene, and toileting. Her diagnoses included fracture of the right lower leg, asthma, type 2 diabetes mellitus, and fibromyalgia. The discharge summary and social services documentation showed that she received notice from her commercial insurance plan that skilled services would no longer be covered and that staff assisted her with filing an appeal. The record also showed that the social services director left a voicemail for the local LTC ombudsman regarding the resident's discharge situation, but the EMR did not contain documentation that the ombudsman was notified in writing before the resident's discharge. During interviews, the social services director stated she normally sent a monthly list of discharges to the ombudsman after the prior month ended and acknowledged that she did not notify the ombudsman in writing of this resident's discharge before discharge occurred. The regional clinical resource stated that this process did not meet regulatory requirements and that the ombudsman should be notified in writing before discharge.
Group Activities Not Provided to Wheelchair-Dependent Residents
Penalty
Summary
The facility failed to provide ongoing group activities designed to support the needs and preferences of two residents who both expressed a desire to participate in outings and activities with peers. The activity policy stated that residents have the right to choose the types of activities and social events in which they wish to participate and are encouraged to do so. Resident #2, who was cognitively intact with diagnoses including cerebral palsy, schizoaffective disorder, bipolar disorder, and muscle weakness, had documented preferences for music, animals, news, group activities, and going outside when the weather was good. Resident #78, also cognitively intact, had diagnoses including PTSD, depression, anxiety disorder, multiple sclerosis, and renal insufficiency, and her assessment documented that she enjoyed group activities and going out when the weather was nice. Resident #2 stated that the facility had a new bus for group activities but it had only one wheelchair space, and she had missed several group outings because other residents had already signed up. She said she was unable to transfer to a seat and required her wheelchair at all times, which made it stressful for her not to be able to participate with her friends. Record review showed her care plan included community outings and other group activities, but the activity log from 11/1/24 through 8/28/25 showed only three outside group trip activities in which she participated and one refusal. Resident #78 stated that she wished she could go out on a group activity with her friends, but the bus could only accommodate one wheelchair and she was often left behind because she could not transfer to a seat. She also said that when she was available, staff told her there were no spots available, and she had not had the opportunity to go on a trip into the community with her friends that year. Staff interviews confirmed the transportation limitation. The activity bus driver said the bus could only accommodate one resident in a wheelchair and that residents in wheelchairs who could not be transferred were often left behind. The activity director said the bus had 12 seats and one wheelchair-accessible spot, that outside group activities were first-come, first-served for residents requiring wheelchairs, and that most residents in wheelchairs were left behind due to the bus limitations. The nursing home administrator stated that residents' participation was based on physical and cognitive abilities and that arrangements would be made when additional transportation assistance was needed, but also said it had not been brought to her attention that residents were concerned about their inability to participate with their peers.
Failure to Follow Up on Telehealth Pulmonology Care
Penalty
Summary
The facility failed to ensure timely follow-up from a telehealth pulmonology appointment for a resident with chronic obstructive pulmonary disease, morbid obesity with alveolar hypoventilation, acute and chronic respiratory failure with hypercapnia and hypoxia, and sleep apnea. The resident was cognitively intact, dependent on staff for most mobility and toileting activities, and on continuous oxygen. He reported that he had been waiting since March 2025 for a CPAP machine and said his pulmonologist had completed and faxed the paperwork to the facility, but he still had not received the machine or been informed of any sleep study scheduling. Record review showed the respiratory care plan addressed altered respiratory status and oxygen use, but the comprehensive care plan did not include a CPAP focus or interventions, and there was no physician order for a CPAP machine. The EMR did not contain progress notes or records from the pulmonology appointments, and the resident’s grievances referenced the unresolved CPAP issue and sleep study. Staff interviews indicated the resident had pre-existing telehealth pulmonology appointments while at the facility, but the HIM was unaware of them, the receptionist said the appointments occurred virtually, and the DON stated telehealth follow-up was harder to track and was unsure whether a sleep study had ever been scheduled.
Failure to Provide Ordered Splinting and PROM for Residents With Contractures
Penalty
Summary
The facility failed to provide proper contracture management services, equipment, and assistance for two residents reviewed for restorative services. One resident had a right hand contracture and was ordered to have a right hand splint applied in the morning and removed in the afternoon, but observations on multiple occasions showed the resident sitting in the hallway, room, and dining room without the splint or a palm protector in place. The resident’s record showed the splint was documented as applied on those days, but progress notes did not document whether the splint was actually applied or whether the resident refused it. Staff interviews indicated that refusals were supposed to be reported and documented, but the observed condition did not match the charted treatment record. The resident’s record also showed diagnoses including schizophrenia, contracture of the right hand, abnormal posture, lack of coordination, and wheelchair dependence. The care plan identified the right hand contracture and included an intervention to ensure the resident’s right hand resting splint was on in the morning and off in the evening, but the musculoskeletal care plan did not include an intervention for the splint. The director of rehabilitation stated that hand splints were used to prevent skin breakdown and prevent contractures, and that staff should report refusals and document them in progress notes. A second resident with multiple sclerosis and bilateral ankle contractures was supposed to receive restorative care including passive range of motion to both ankles and splint or brace assistance twice per week, with Multi Podus boots when up in the wheelchair. During a continuous observation, a CNA entered the resident’s room twice but did not provide PROM during either visit, and no other staff entered the room during the observation period. The resident stated that the restorative program had been non-existent and that PROM was supposed to occur twice weekly but was rarely provided. The record review did not reveal documentation that PROM had been provided from May through August 2025, and staff interviews confirmed that the resident was on a restorative program for PROM, but documentation was absent.
Failure to Supervise a Resident With Elopement Risk
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and adequate supervision for one resident with a history of elopement. Resident #5 had diagnoses including COPD, acute and chronic respiratory failure, major depressive disorder, anxiety disorder, and dementia, and the MDS showed severe cognitive impairment with a BIMS score of 7, dependence for toileting, touch assistance for personal hygiene, set-up assistance for eating, use of a manual wheelchair, and a wander guard in place. The behavior and wandering care plan identified the resident as an elopement risk related to dementia with agitation and a history of exit-seeking behaviors, with interventions that included supervision while smoking. During observation, the resident self-propelled out of the building and into the smoking patio area while other residents were entering, and there were no staff members present in the smoking area. He waited outside for the supervised smoking break until an activity assistant later arrived with cigarettes and assisted residents with smoking. On another observation, the resident again self-propelled through the exit door while other residents were going to smoke, and his wander guard alarm did not activate. There was no staff member in the area, and the resident remained outside until another resident alerted staff that he was there without supervision. The smoking area was observed to have a fence with an unsecured gate entrance leading directly to the street. Staff interviews confirmed the resident had wandering and exit-seeking behaviors and required supervision whenever he was outside the building. The DON stated staff were responsible for ensuring unsafe smokers were adequately supervised, and the NHA stated the facility had not completed its own assessment of the resident's wandering behavior.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate was not greater than 5%, with surveyors identifying a 10.3% error rate, or three errors out of 29 opportunities for error. The cited events involved medication administration errors with inhalers and insulin, and the report included review of facility policies, physician orders, direct observations, and staff interviews related to those administrations. For one resident with COPD, an LPN observed the resident self-administer a Symbicort inhaler and did not instruct the resident to take the second puff ordered or to rinse and spit after use. The resident’s physician order directed two puffs twice daily and to rinse and spit after inhaler use. The LPN later stated she thought she saw a second puff and acknowledged the resident should have rinsed after using the inhaler to help prevent thrush. For another resident with COPD, an RN allowed self-administration of a Dulera inhaler but did not instruct the resident to rinse and spit after use, despite the physician’s order requiring it. The RN stated the resident usually self-administered the inhaler and had been educated several times to rinse and spit after use. For a third resident receiving Lantus insulin by pen injector, an RN administered 13 units, then later returned to give the remaining 2 units after realizing the order was for 15 units total. During both administrations, the RN failed to prime the insulin pen before giving the dose. The RN stated she was not clear on the correct priming process and said priming was important to remove air so the resident would receive the full dose. The DON and pharmacy consultant both stated the insulin pen needed to be primed before administration and that the resident should have received the full ordered dose.
Insulin Pen Not Primed Before Administration
Penalty
Summary
Ensure that residents were free from significant medication errors was not met when insulin pen priming was not performed in a manner consistent with professional standards of practice for one resident. Resident #99, who had diagnoses including type 2 diabetes mellitus, local infection of the skin and subcutaneous tissue, and infective myositis, was cognitively intact with a BIMS score of 15 out of 15 and was dependent on staff for several ADLs. During a continuous observation, an RN entered the resident’s room to check blood glucose and administer medications, including insulin via an insulin pen injector, after the resident requested a brief change. After oral medications were given and blood glucose was checked, the RN prepared the insulin pen and turned the dosage selector to 13 units, but did not prime the pen before administering insulin to the resident’s right abdomen. The RN then realized the physician’s order was for 15 units, returned to the medication cart, and prepared to give the remaining two units. Before re-entering the room, she turned the dosage selector to two units and again did not prime the insulin pen before administering the remaining dose to the resident’s left abdomen. The RN later stated she was not clear on the correct priming process, while the pharmacy consultant and DON stated that the needle must be attached and the pen primed before administration so the resident receives the full dose.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored, secured, and labeled in accordance with accepted professional standards in two medication carts and one medication storage room. During observation of the medication storage room, multiple bubble packs of medications for two discharged residents were found sitting out on the counter. The regional clinical resource and RN #1 were present during the observation, and the medications were identified as belonging to Resident #9 and Resident #31. Additional observations of the hallway D medication cart and hallway A medication cart found medications stored in labeled medication boxes, but the individual containers inside were not labeled with the resident's name or the date the medication was opened. In hallway D, two fluticasone propionate nasal spray bottles for two residents were missing this information, and in hallway A, a semaglutide oral tablet medication for another resident was also missing the resident's name and open date. The regional clinical resource stated that discharged residents' medications should have been brought to the DON's office after discharge, and stated she did not know medication containers needed to be labeled when stored inside their medication boxes.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain an infection control program on one of six units when RN #1 did not clean Resident #99’s glucometer according to the manufacturer’s instructions. During medication administration, RN #1 completed a blood sugar check and then used a Medline micro-kill germicidal-bleach wipe to clean the glucometer, but spent less than ten seconds wiping the device and the surface did not become visibly wet. The manufacturer guidance provided by the NHA stated the meter should be cleaned and disinfected between patient use with an EPA-registered disinfectant wipe, and the wipe label required the surface to remain visibly wet for 30 seconds to kill bacteria and viruses. RN #1 later stated she was unclear on the manufacturer guidelines and initially believed the cleaning time was three minutes. The facility also failed to ensure proper hand hygiene during medication administration. While administering Resident #99’s oral medications, RN #1 was asked for fresh ice water, but she did not remove her gloves or perform hand hygiene before leaving the room. She walked to the ice cooler, handled the lid and scoop, filled the resident’s cup with ice, returned to the room, and filled the cup with water from the faucet using the same gloved hands before continuing medication administration. The facility’s infection control policy stated that universal precautions, handwashing, and aseptic practices are followed by personnel, and the DON stated hand hygiene should be performed when the nurse left the resident’s room during medication administration.
Failure to Implement Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, which is a requirement according to their policy. The baseline care plans lacked essential medical information necessary for providing effective and person-centered care. This deficiency was identified during a review of records and interviews with staff members. Resident #3, who was under 65 years old, was admitted with a PASRR Level II evaluation indicating diagnoses of schizophrenia and bipolar I disorder with psychotic features. The evaluation highlighted the need for specialized services such as psychiatry case consultation and behavior management. However, the baseline care plan for this resident did not include these PASRR findings or the required specialized services. Resident #11, also under 65, was admitted with diagnoses including metabolic encephalopathy and end-stage renal failure. The hospital's transition report specified dietary restrictions and the need for hemodialysis and oxygen, but these were not included in the baseline care plan. Similarly, Resident #14, aged 88, was admitted with a need for a diabetic diet and oxygen, which were omitted from the baseline care plan. Interviews with staff revealed that the admitting nurse was responsible for initiating the baseline care plan, but the plans failed to include critical information such as diet specifications and PASRR information.
Failure to Provide Personalized Activity Programs for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of residents, specifically for three residents reviewed. The activity calendar for February 2025 showed limited variety and personalization, with repetitive activities like Bingo and insufficient options for non-social dementia residents. Observations revealed that residents were often left idle or engaged in passive activities like watching TV, without meaningful interaction or encouragement from staff. Resident #10, diagnosed with Alzheimer's disease and dementia, was observed sitting idle in the activities room and not participating in scheduled activities. Despite having a care plan that highlighted her interest in music, animals, and religious services, she was not assisted to attend a Catholic communion service, which was important to her. Her activity participation records indicated a lack of engagement in creative activities, and her one-on-one activities were limited to receiving the daily activities calendar and coloring pages. Resident #6, with a cognitive communication deficit and dementia, was often found sleeping or watching TV in the common area, with no meaningful activities provided. Her care plan emphasized the importance of structured activities and social interaction, yet observations showed a lack of engagement in activities she enjoyed, such as bingo. Similarly, Resident #4, with severe cognitive impairments, was frequently observed sitting in front of the TV without interaction or meaningful activities. Her care plan noted her preference for music and outdoor activities, but there was no evidence of these being offered or encouraged, and her one-on-one activity program had been discontinued without reattempts to engage her.
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Illustrative
What surveyors actually found near you
We read the 42 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pueblo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atlas Post Acute | 1.1 mi | ★★★★★ | 5 | 0 |
| Rock Canyon Respiratory And Rehabilitation Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Pueblo | 2.2 mi | ★★★★★ | 2 | 0 |
| High Plains Post Acute Llc | 3.2 mi | ★★★★★ | 6 | 0 |
| Vista Ridge Care And Rehabilitation | 4.8 mi | ★★★★★ | 20 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.