Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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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What surveyors actually found near you
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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.
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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 | — | 2 | 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 | — | 0 | 0 |
| Pavilion At Villa Pueblo, The | 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 August 2026) and official state health department websites.