Inspection Reports for
Lakeshore Post Acute and Rehabilitation Center
2701 CALIFORNIA ST, PUEBLO, CO, 81004-3869
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
112% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 9
Date: Aug 28, 2025
Visit Reason
Routine inspection of Lakeshore Post Acute and Rehabilitation Center to assess compliance with regulatory requirements including resident care, medication administration, environment safety, and infection control.
Findings
The facility had multiple deficiencies including failure to notify the ombudsman in writing prior to resident discharge, inadequate group activities for residents with mobility limitations, failure to follow up on telehealth pulmonology appointments, improper contracture management, inadequate supervision of a resident with elopement risk, medication errors exceeding 5%, improper medication storage and labeling, infection control lapses including improper glucometer cleaning and hand hygiene, and maintenance issues affecting resident safety and comfort.
Deficiencies (9)
F0628: Facility failed to notify the ombudsman in writing prior to discharge of Resident #97, violating discharge notification requirements.
F0679: Facility failed to provide ongoing group activities meeting the preferences of Residents #2 and #78, limiting participation due to wheelchair accessibility issues.
F0684: Facility failed to ensure timely follow-up from telehealth pulmonology appointments for Resident #1, resulting in no sleep study or CPAP machine ordered.
F0688: Facility failed to provide proper contracture management for Residents #66 and #37, including inconsistent application of wrist splint and lack of passive range of motion therapy.
F0689: Facility failed to provide adequate supervision to prevent elopement risk for Resident #5, who exited the building unsupervised and with a non-functioning wander guard.
F0759: Facility medication error rate was 10.3%, including failure to instruct residents to rinse mouth after inhaler use and failure to prime insulin pen prior to administration for Resident #99.
F0761: Facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled, including medications of discharged residents and unlabeled medication containers.
F0880: Facility failed to maintain an infection control program, including improper cleaning of glucometers and failure to perform hand hygiene during medication administration.
F0921: Facility failed to provide a safe, functional, sanitary, and comfortable environment, with maintenance issues including water leaks, missing vents, rusty ventilation, loose handrails, and difficult-to-open resident room doors.
Report Facts
Medication error rate: 10.3
Medication error count: 3
Resident sample size: 55
Wander guard replacement interval: 90
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Involved in medication administration errors including insulin pen priming and hand hygiene lapses. |
| LPN #3 | Licensed Practical Nurse | Failed to instruct resident on inhaler use and mouth rinsing, contributing to medication errors. |
| RN #2 | Registered Nurse | Failed to instruct resident on inhaler mouth rinsing after medication administration. |
| CNA #8 | Certified Nurse Aide | Reported Resident #66's refusal to wear splint and described splint application process. |
| Director of Nursing | DON | Provided interviews regarding medication administration standards, infection control, and supervision. |
| Nursing Home Administrator | NHA | Provided facility policies, interviews on maintenance and regulatory compliance. |
| Regional Clinical Resource | RCR | Interviewed regarding discharge notification and medication storage. |
| Infection Preventionist | IP | Interviewed regarding infection control practices including glucometer cleaning and hand hygiene. |
| Maintenance Director | MTD | Interviewed regarding facility maintenance issues and work order process. |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to baseline care planning and activities programming for residents at Lakeshore Post Acute and Rehabilitation Center.
Findings
The facility failed to develop and implement baseline care plans within 48 hours of admission that included pertinent medical information for three residents. Additionally, the facility failed to provide personalized and meaningful activities to support residents' physical, mental, and psychosocial well-being for three residents reviewed for activities programming.
Deficiencies (2)
F 0655: The facility failed to develop and implement baseline care plans within 48 hours of admission that included pertinent medical information such as PASRR findings and specialized services for three residents (#3, #11, and #14).
F 0679: The facility failed to provide an ongoing program of personalized activities that met the interests and supported the well-being of three residents (#10, #6, and #4), including failure to engage residents in meaningful activities and to encourage participation.
Report Facts
Sample residents reviewed: 22
Residents with deficient baseline care plans: 3
Residents with deficient activities programming: 3
BIMS scores: 15
BIMS score: 14
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding baseline care plan initiation | |
| Director of Nursing (DON) | Interviewed regarding baseline care plan requirements and initiation | |
| Nursing Home Administrator (NHA) | Interviewed regarding baseline care plan policy | |
| Social Services Corporate Consultant (SSCC) | Interviewed regarding baseline care plan and activities programming | |
| Activity Director (AD) | Interviewed regarding activities programming and resident engagement |
Inspection Report
Routine
Deficiencies: 14
Date: Oct 26, 2023
Visit Reason
Routine inspection of Lakeshore Post Acute and Rehabilitation Center to assess compliance with regulatory requirements including resident rights, environment, abuse prevention, restraint use, respiratory care, dementia care, medication management, infection control, and staff training.
Findings
The facility had multiple deficiencies including failure to address resident grievances, maintain a safe and sanitary environment, prevent resident abuse, ensure proper restraint use, provide appropriate respiratory care, manage dementia and psychotropic medications properly, maintain food safety standards, and implement effective infection control measures including COVID-19 precautions. Staff training on dementia management was also lacking.
Deficiencies (14)
F 0565: Facility failed to provide response, action and rationale to residents involved in group grievances concerning resident care and dignity.
F 0584: Facility failed to maintain a sanitary, orderly and comfortable environment in 14 of 60 resident rooms, including damaged walls, peeling paint, and broken fixtures.
F 0600: Facility failed to prevent resident-to-resident abuse involving Resident #58 and others, resulting in altercations.
F 0604: Facility failed to obtain physician orders, consents, and ongoing evaluations for lap buddy restraints used on Residents #52 and #11.
F 0609: Facility failed to report alleged verbal abuse by a nurse towards Resident #54 in accordance with State law.
F 0659: Facility failed to provide services by qualified persons when Resident #71 was not assessed by a registered nurse following a fall.
F 0685: Facility failed to provide hearing assistive devices and staff education on their use for Resident #22.
F 0689: Facility failed to ensure Resident #58 wore non-skid footwear while ambulating as identified in the care plan.
F 0695: Facility failed to administer oxygen per physician order for Resident #183, who was observed without oxygen and with low oxygen saturation.
F 0744: Facility failed to develop individualized care plans and train staff on interventions for aggressive behaviors for Resident #58 with dementia.
F 0758: Facility failed to monitor behaviors and non-pharmacological interventions for psychotropic medications, follow pharmacist recommendations for dose reductions, and ensure PRN psychotropic orders had appropriate stop dates for multiple residents.
F 0812: Facility failed to ensure foods of modified consistency were reheated to safe temperatures, cutting boards were free from deep scratches and stains, and kitchen staff wore beard restraints.
F 0880: Facility failed to maintain an infection control program ensuring hand hygiene between glove use, proper PPE use when entering COVID positive rooms, and preventing COVID positive residents from accessing areas frequented by COVID negative residents.
F 0947: Facility failed to provide annual dementia management training for six certified nurse aides.
Report Facts
Residents COVID-19 positive: 11
Residents affected by environmental deficiencies: 14
Residents affected by abuse: 2
Residents affected by restraint deficiencies: 2
Residents affected by respiratory care deficiencies: 1
Residents affected by hearing aid deficiencies: 1
Residents affected by footwear deficiencies: 1
Residents affected by dementia care deficiencies: 1
Residents affected by psychotropic medication deficiencies: 5
Residents affected by food safety deficiencies: many
Certified nurse aides lacking annual dementia training: 6
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 9, 2023
Visit Reason
The inspection was conducted based on complaints and observations regarding failure to provide timely incontinent care, pressure ulcer prevention and treatment, proper repositioning, and adequate hydration for residents.
Complaint Details
The complaint investigation focused on allegations of inadequate incontinent care, pressure injury prevention and treatment, improper repositioning techniques, and insufficient hydration for residents.
Findings
The facility failed to provide timely incontinent care and repositioning for dependent residents, failed to follow physician orders for pressure injury treatment, failed to properly reposition residents using gait belts, and failed to ensure residents received adequate hydration according to assessed needs.
Deficiencies (4)
F 0677: The facility failed to provide timely incontinent care and positioning for dependent residents #9 and #5, resulting in potential harm related to pressure injury risk.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for residents #1 and #2, including failure to follow physician orders and implement pressure relief interventions.
F 0689: The facility failed to ensure proper repositioning of residents #9, #10, #4, and #6 in wheelchairs using gait belts, increasing risk of skin injury from friction and shear.
F 0692: The facility failed to provide adequate hydration to residents #1, #3, #5, and #9, resulting in dehydration and failure to meet minimum fluid intake recommendations.
Report Facts
Fluid intake: 600
Fluid intake: 1340
Fluid intake: 1590
Fluid intake: 777
Fluid intake: 1375
Fluid intake: 1500
Fluid intake: 480
Fluid intake: 1200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding incontinent care for Resident #9 |
| DON | Director of Nursing | Interviewed regarding incontinent care, pressure injury treatment, hydration, and repositioning |
| CNA #3 | Certified Nursing Assistant | Observed and interviewed regarding care of Resident #9 |
| CNA #5 | Certified Nursing Assistant | Observed and interviewed regarding care of Resident #9 |
| CNA #6 | Certified Nursing Assistant | Interviewed regarding shift handoff and incontinence care |
| WCPA | Wound Care Physician Assistant | Interviewed regarding pressure injury prevention and treatment |
| RN #3 | Registered Nurse | Interviewed regarding hydration and resident care |
| CNA #8 | Certified Nursing Assistant | Interviewed regarding hydration and feeding assistance |
| PT | Physical Therapist | Interviewed regarding proper repositioning techniques |
| RCNA Trainer | Restorative Certified Nursing Assistant Trainer | Interviewed regarding repositioning training |
| NHA | Nursing Home Administrator | Interviewed regarding staff training on gait belt use |
| RD | Registered Dietician | Interviewed regarding hydration and nutrition assessments |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 7, 2022
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident care, transfer and discharge procedures, bed-hold policies, and medication administration.
Findings
The facility was found deficient in ensuring call lights were within reach of residents, providing timely and written notification of transfers and bed-hold policies to residents or their representatives, and maintaining medication error rates below 5%. Several residents experienced delays in assistance and medication administration errors were observed.
Deficiencies (4)
F 0558: The facility failed to ensure a call light was within reach of Resident #40, resulting in a 30-minute delay in assistance.
F 0623: The facility failed to provide written notification of a facility-initiated transfer to Resident #5 or their representative.
F 0625: The facility failed to notify Resident #5 or their representative in writing about the bed-hold and reserve bed payment policy upon hospital transfer.
F 0759: The facility failed to maintain a medication error rate below 5%, with three errors in 34 opportunities observed during medication administration for Residents #3 and #13.
Report Facts
Medication error rate: 8.82
Medication errors: 3
Medication administration opportunities: 34
Response time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Involved in medication administration errors for Residents #3 and #13. |
| CNA #1 | Certified Nursing Assistant | Observed providing care to Resident #40 and confirmed call light was out of reach. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding call light policies and resident care. |
| Director of Nursing | Director of Nursing | Interviewed regarding transfer notification and medication administration expectations. |
| Administrator | Administrator | Interviewed regarding transfer notification, bed-hold policies, and medication administration expectations. |
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