A
LAKESHORE POST ACUTE AND REHABILITATION CENTER
81/100 score
0.87 hrs RN staffing
10 deficiencies
CENTER AT PARK WEST LLC, THE
3727 PARKER BLVD, PUEBLO, CO 81008
B
Facility Assessment
Inspectors recorded 2 citations at the actual-harm level or worse in the last three survey cycles.
At or above the 2024 benchmark — above average inspection record.
Quality Breakdown
|
RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
|
1.27 — At or above the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
|
|
Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
|
Total
20
Outstanding
0
Actual harm or worse (G–L)
2
|
|
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
|
Quality: ★★★★★ (5/5)
Staffing: ★★★☆☆ (3/5)
|
|
NursingHomeGrade Score
|
66/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
2 actual harm issues found among 20 total deficiencies. 20 corrected.
Most recent inspection (August 1, 2024)
D
Potential harm — isolated
F0849
Status: Corrected
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Administration Deficiencies — Deficient, Provider has date of correction, corrected August 23, 2024
D
Potential harm — isolated
F0947
Status: Corrected
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 — Deficient, Provider has date of correction, corrected August 23, 2024
D
Potential harm — isolated
F0758
Status: Corrected
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 — Deficient, Provider has date of correction, corrected August 23, 2024
D
Potential harm — isolated
F0677
Status: Corrected
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2025
G
Actual harm — isolated
F0684
Status: Corrected
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2025
G
Actual harm — isolated
F0686
Status: Corrected
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2025
E
Potential harm — pattern
F0744
Status: Corrected
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2025
D
Potential harm — isolated
F0689
Status: Corrected
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 23, 2024
D
Potential harm — isolated
F0697
Status: Corrected
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 23, 2024
E
Potential harm — pattern
F0655
Status: Corrected
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 — Deficient, Provider has date of correction, corrected October 24, 2025
D
Potential harm — isolated
F0585
Status: Corrected
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 24, 2025
E
Potential harm — pattern
F0583
Status: Corrected
Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 23, 2024
Inspection cycle 3 (January 6, 2022)
F
Potential harm — widespread
F0880
Status: Corrected
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 18, 2022
F
Potential harm — widespread
F0886
Status: Corrected
Perform COVID19 testing on residents and staff.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 4, 2022
F
Potential harm — widespread
F0803
Status: Corrected
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 24, 2022
D
Potential harm — isolated
F0758
Status: Corrected
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 — Deficient, Provider has date of correction, corrected February 4, 2022
E
Potential harm — pattern
F0695
Status: Corrected
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 14, 2022
D
Potential harm — isolated
F0697
Status: Corrected
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 4, 2022
D
Potential harm — isolated
F0744
Status: Corrected
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 4, 2022
E
Potential harm — pattern
F0563
Status: Corrected
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 4, 2022
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