Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LAKESHORE POST ACUTE AND REHABILITATION CENTER
PUEBLO, CO · 106 certified beds · Last Life Safety survey October 26, 2023
CMS Certification Number 065229 · first certified April 1986
Ownership
Operated by THE ENSIGN GROUP · For profit - Corporation
- Ownership changed September 1, 2024 (change of ownership)from DESERT WILLOW HEALTH AND REHABILITATION CENTER LLC
Position within CO
40 citations — more than 98% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 20 citations; the earlier surveys in the window averaged 10. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (April 2025 to October 2025), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was October 2023. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
9 of the 40 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 40 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0584 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.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 40 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 7, 2021 | 10 |
| July 7, 2022 | 10 |
| October 26, 2023 | 20 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 3 | 2023-10-26 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2023-10-26 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2022-07-07 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2023-10-26 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2022-07-07 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2023-10-26 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2021-04-07 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2022-07-07 |
What the citations cover
- Smoke Deficiencies 14
- Emergency Preparedness Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Egress Deficiencies 5
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 14 |
| Emergency Preparedness Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Egress Deficiencies | 5 |
| Services Deficiencies | 4 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 26, 2023 — 20 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (November 24, 2023) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (November 24, 2023) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (November 24, 2023) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (November 24, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (November 24, 2023) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (November 24, 2023) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (November 24, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (November 24, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (November 24, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (January 22, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (January 22, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 22, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 22, 2024) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (January 22, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 22, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Past Non-Compliance (October 26, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (January 22, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (January 22, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (January 22, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 22, 2024) |
July 7, 2022 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0226 | Have horizontal exits used in accordance with safety requirements. | Deficient, Provider has date of correction (July 29, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 11, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (November 11, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 5, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 2, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 22, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 10, 2022) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (August 10, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 5, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 5, 2022) |
April 7, 2021 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (May 7, 2021) |
| K-0227 | Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Waiver has been granted (November 5, 2021) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 7, 2021) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (May 21, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 19, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 7, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (May 19, 2021) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 16, 2021) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (May 18, 2021) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (June 4, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.