Lakeshore Post Acute and Rehabilitation Center
2701 California St, Pueblo, CO 81004
Lakeshore Post Acute and Rehabilitation Center is a nursing home in Pueblo, Colorado. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating4 of 5
- Last standard health inspectionAugust 28, 2025 (1 year ago)
- Health citations since July 7, 202230 (Colorado average 25)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of November 20, 2025
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
Health inspection on August 28, 2025
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation F0921. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on September 24, 2025.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on September 24, 2025.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on September 24, 2025.
CMS has cited this home for F0679 2 times since 2025.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on September 24, 2025.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 24, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 24, 2025.
CMS has cited this home for F0689 2 times since 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on September 24, 2025.
CMS has cited this home for F0759 2 times since 2022.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on September 24, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 24, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 24, 2025.
CMS has cited this home for F0880 2 times since 2023.
CMS update of May 28, 2025
Name
CMS lists a new legal business name for this home.
Ownership
CMS lists this home under a new chain.
Ownership
CMS ownership records list new owners for this home.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Health inspection on February 26, 2025
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0655. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on April 1, 2025.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on April 1, 2025.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Changed ownership in the last 12 months
CMS records show a change of ownership in the past 12 months.
Staffing
Total nurse staffing reported to CMS went from 3.4 to 1.2 hours per resident per day.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
CMS update of September 26, 2024
Name
CMS lists a new name for this home. It was DESERT WILLOW HEALTH AND REHABILITATION CENTER.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of February 29, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.6 to 2.4 hours per resident per day.
Health inspection on October 26, 2023
14 citationsCMS lists this as a standard inspection.
Show the 14 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 24, 2023.
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on November 24, 2023.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 24, 2023.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 24, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on December 13, 2023.
Citation F0947. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on November 24, 2023.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on January 23, 2024.
Citation F0604. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on November 24, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 24, 2023.
Citation F0659. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care by qualified persons according to each resident's written plan of care.
CMS lists it as corrected on November 24, 2023.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on December 19, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 24, 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on December 6, 2023.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on November 24, 2023.
Fire safety inspection on October 26, 2023
20 citationsCMS lists this as a standard inspection.
Show the 20 citations
Citation E0015. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on November 24, 2023.
Citation E0018. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish procedures for tracking staff and patients during an emergency.
CMS lists it as corrected on November 24, 2023.
Citation E0023. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for medical documentation.
CMS lists it as corrected on November 24, 2023.
Citation E0026. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on November 24, 2023.
Citation E0029. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop a communication plan.
CMS lists it as corrected on November 24, 2023.
Citation E0031. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide emergency officials' contact information.
CMS lists it as corrected on November 24, 2023.
Citation E0033. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish methods for sharing information.
CMS lists it as corrected on November 24, 2023.
Citation E0036. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on November 24, 2023.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on November 24, 2023.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on January 22, 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on January 22, 2024.
Citation K0346. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
CMS lists it as corrected on January 22, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 22, 2024.
CMS has cited this home for K0353 3 times since 2021.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on October 26, 2023.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on January 22, 2024.
CMS has cited this home for K0521 3 times since 2021.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on January 22, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 22, 2024.
CMS has cited this home for K0918 2 times since 2022.
Citation K0222. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on January 22, 2024.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on January 22, 2024.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on January 22, 2024.
Health inspection on July 7, 2022
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on July 30, 2022.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on July 30, 2022.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 30, 2022.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on July 30, 2022.
Fire safety inspection on July 7, 2022
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on August 11, 2022.
CMS has cited this home for K0321 2 times since 2021.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on November 11, 2022.
Citation K0355. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on August 5, 2022.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on August 2, 2022.
CMS has cited this home for K0363 2 times since 2021.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on August 22, 2022.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 10, 2022.
Citation K0741. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on August 10, 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on August 5, 2022.
Citation K0226. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have horizontal exits used in accordance with safety requirements.
CMS lists it as corrected on July 29, 2022.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on August 5, 2022.
Fire safety inspection on April 7, 2021
10 citationsCMS lists this as a standard inspection.
Show the 10 citations
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on May 7, 2021.
Citation K0919. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on June 4, 2021.
Citation K0227. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
CMS lists it as corrected on November 5, 2021.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on May 7, 2021.
Citation K0325. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed hallway dispensers for alcohol-based hand rub.
CMS lists it as corrected on May 21, 2021.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on May 19, 2021.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on May 7, 2021.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 19, 2021.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on June 16, 2021.
Citation K0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on May 18, 2021.
CMS star ratings
- 4 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (719) 561-1300
- Last standard health inspection
- August 28, 2025 (1 year ago)
- Certified beds
- 106
- Residents per day, on average
- 81.8
- Ownership type
- For profit - Corporation
- Legal business name
- Steel City Healthcare, INC.
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
More health citations than the Colorado average (30 vs 25).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- PRIME TIME HEALTHCARE LLCOperational/managerial control · not applicable · since 09/01/2024
- MALONEY, ANNOperational/managerial control · not applicable · since 09/01/2024
- REDDY, VIKASOperational/managerial control · not applicable · since 09/01/2024
Questions
When was Lakeshore Post Acute and Rehabilitation Center last inspected?
CMS lists August 28, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Lakeshore Post Acute and Rehabilitation Center have?
CMS lists 30 health citations since July 7, 2022. CMS also calls these deficiencies.
Has Lakeshore Post Acute and Rehabilitation Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Lakeshore Post Acute and Rehabilitation Center?
Its CMS overall star rating is 4 of 5.
Is Lakeshore Post Acute and Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.