CCN 065229

Lakeshore Post Acute and Rehabilitation Center

2701 CALIFORNIA ST, Pueblo, CO 81004 · Pueblo County

Phone: (719) 561-1300
Ownership: For profit - Corporation
Certified beds: 106
Residents per day: 81.1
Health citations: 30
Penalties: 0
Fines: 0 · $0
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 5 · short-stay 4.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 2.07; 2.21; 2.32
LPN/LVN: 0.58; 0.68; 0.86
Registered nurse: 0.73; 0.82; 0.69
Total nurse staff: 3.38; 3.72; 3.86
Weekend total: 2.99; 3.29; 3.42
Weekend RN: 0.49; 0.60; 0.48

Adjusted total nurse hours: 3.38. Adjusted RN hours: 0.73. Case-mix total: 3.83. Case-mix index: 1.401.

Total nursing staff turnover: 44.1%. RN turnover: 37.5%. Administrators who left: 0.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 0 fines totaling $0, and 0 payment denials.

The Penalties file has no individual penalty rows for this CCN.

Cycle 1 standard survey: August 28, 2025. Health deficiencies counted in cycle 1: 10. Cycle 1 total health score: 44.

Cycle 2 standard survey: October 26, 2023. Cycle 2/3 health deficiencies: 16. Total weighted health survey score: 59.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 30 citations for this home, including 0 at immediate jeopardy and 0 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

August 28, 2025

10 citations

Tag	What CMS cited	Scope and severity	Status
F921	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 24, 2025
F628	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 24, 2025
F679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 24, 2025
F684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 24, 2025
F688	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. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 24, 2025
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 24, 2025
F759	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 24, 2025
F760	Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 24, 2025
F761	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. Pharmacy Service Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 24, 2025
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 24, 2025

February 26, 2025

2 citations

Tag	What CMS cited	Scope and severity	Status
F655	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 1, 2025
F679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · April 1, 2025

October 26, 2023

14 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F565	Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F584	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. Resident Rights Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F758	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. Pharmacy Service Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 13, 2023
F947	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F600	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 23, 2024
F604	Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F609	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F659	Provide care by qualified persons according to each resident's written plan of care. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F685	Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 19, 2023
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 6, 2023
F744	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023

July 7, 2022

4 citations

Tag	What CMS cited	Scope and severity	Status
F558	Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 30, 2022
F623	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 30, 2022
F625	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. Resident Rights Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 30, 2022
F759	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · July 30, 2022

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
Chain name in the file: The Ensign Group (344 facilities). Chain average overall rating: 3.2.
Legal business name: Steel City Healthcare, INC..
First approved for Medicare and Medicaid services: April 1, 1986.
Resident and family council: Resident.
Automatic sprinklers in all required areas: Yes.
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Questions

What is the CMS overall rating for Lakeshore Post Acute and Rehabilitation Center?

Lakeshore Post Acute and Rehabilitation Center has an overall rating of 4 out of 5. The health inspection rating is 3, staffing is 3, and the quality measure rating is 5.

How many health citations does CMS list for Lakeshore Post Acute and Rehabilitation Center?

The Health Deficiencies file lists 30 health citations for this home. 0 are coded immediate jeopardy (J, K, or L) and 0 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for Lakeshore Post Acute and Rehabilitation Center?

CMS reports 3.38 total nurse hours per resident per day, including 0.73 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Opening the record…

October 26, 2023

14 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F565	Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F584	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. Resident Rights Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F758	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. Pharmacy Service Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 13, 2023
F947	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Standard survey · Cycle 2	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F600	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · January 23, 2024
F604	Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F609	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F659	Provide care by qualified persons according to each resident's written plan of care. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F685	Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 19, 2023
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · December 6, 2023
F744	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · November 24, 2023