Facility Watch Inspection records for every certified US nursing home

Lakeshore Post Acute and Rehabilitation Center

2701 California ST
Pueblo, CO 81004
(719) 561-1300

CCN
065229
Certified beds
106
Ownership
For profit - Corporation
Chain
THE Ensign Group

Nurse staffing

3.60
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.89 hours per resident per day

Nursing staff turnover: 42% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected August 28, 2025

10 citations · Health
D
F0628 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected September 24, 2025
D
F0679 No actual harm with potential for more than minimal harm · Isolated

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected September 24, 2025
D
F0684 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected September 24, 2025
D
F0688 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected September 24, 2025
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected September 24, 2025
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected September 24, 2025
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected September 24, 2025
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected September 24, 2025
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected September 24, 2025
E
F0921 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected September 24, 2025

Inspected February 26, 2025

2 citations · from a complaint investigation · Health
E
F0655 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected April 1, 2025
E
F0679 No actual harm with potential for more than minimal harm · Pattern

Provide activities to meet all resident's needs.

Deficient, Provider has date of correction · corrected April 1, 2025

Inspected October 26, 2023

14 citations · Health
D
F0600 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected January 23, 2024
D
F0604 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 24, 2023
D
F0609 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 24, 2023
D
F0659 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 24, 2023
D
F0685 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 19, 2023
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 24, 2023
D
F0695 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 6, 2023
D
F0744 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected November 24, 2023
E
F0565 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected November 24, 2023
E
F0584 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected November 24, 2023
E
F0758 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected November 24, 2023
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected December 13, 2023
E
F0947 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected November 24, 2023
F
F0812 No actual harm with potential for more than minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected November 24, 2023

Inspected July 7, 2022

4 citations · Health
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected July 30, 2022
D
F0623 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 30, 2022
D
F0625 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 30, 2022
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected July 30, 2022

Ownership transfers

EffectiveSellerBuyer
09/01/2024Desert Willow Health and Rehabilitation Center LLCSteel City Healthcare, Inc.

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.