C76

LAKEWOOD POST ACUTE AND REHABILITATION

Grade C 76/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
4/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

108

Ownership

For profit - Limited Liability company

Total Fines

$49,137

Last Survey

N/A

7395 W EASTMAN PL, LAKEWOOD, CO 80227
3037308000

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
1.31h
LPN
1.25h
CNA
3.11h
Total
5.67h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

PANTHER MASTER TENANT, LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Sep 2023

100%

PACS GROUP, INC.

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Sep 2023

PACS HOLDINGS, LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Sep 2023

PROVIDENCE GROUP NH, LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Sep 2023

HANCOCK, MARK

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Apr 2024

MURRAY, JASON

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Apr 2024

APT, FREDERICK

IndividualCORPORATE OFFICERSince Jan 2024

HANCOCK, MARK

IndividualCORPORATE OFFICERSince Jan 2024

JERGENSEN, JOSHUA

IndividualCORPORATE OFFICERSince Jan 2024

MITCHELL, JOHN

IndividualCORPORATE OFFICERSince Jan 2024

JAVERY, SHAHID

IndividualCONTRACTED MANAGING EMPLOYEESince Jul 2023

BIRRELL, AUSTIN

IndividualW-2 MANAGING EMPLOYEESince May 2024

Penalties & Fines (3)

$49,137total fines
DateTypeDescriptionAmount
Sep 28, 2023Fine$32,513
Sep 28, 2023Payment Denial
Apr 19, 2023Fine$16,624

Health Inspection Deficiencies (34)

March 27, 2025Health11 deficiencies
0552DMinimal harm, Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected May 9, 2025
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected May 9, 2025
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected May 9, 2025
0695DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected May 9, 2025
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected May 9, 2025
0730EMinimal harm, Pattern

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Corrected May 9, 2025
0742DMinimal harm, Isolated

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Quality of Life and Care Deficiencies

Corrected May 9, 2025
0758DMinimal harm, Isolated

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

Corrected May 9, 2025
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected May 9, 2025
0943EMinimal harm, Pattern

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 9, 2025
0808DMinimal harm, Isolated

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Nutrition and Dietary Deficiencies

Corrected May 9, 2025
September 28, 2023Health12 deficiencies2 severe
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Oct 22, 2023
0578EMinimal harm, Pattern

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Corrected Oct 22, 2023
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 22, 2023
0658EMinimal harm, Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 22, 2023
0692GActual harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Oct 22, 2023
0695DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Oct 22, 2023
0697GActual harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Dec 19, 2023
0726EMinimal harm, Pattern

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nursing and Physician Services Deficiencies

Corrected Oct 22, 2023
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Oct 22, 2023
0761FMinimal harm, Widespread

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.

Pharmacy Service Deficiencies

Corrected Dec 19, 2023
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Oct 22, 2023
0883EMinimal harm, Pattern

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Oct 22, 2023
April 19, 2023Health1 deficiency1 severe
0684GActual harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected May 19, 2023
February 25, 2020Health10 deficiencies
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Mar 23, 2020
0577DMinimal harm, Isolated

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Resident Rights Deficiencies

Corrected Mar 23, 2020
0584EMinimal 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.

Resident Rights Deficiencies

Corrected Mar 23, 2020
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 23, 2020
0684DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Mar 23, 2020
0695EMinimal harm, Pattern

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

Quality of Life and Care Deficiencies

Corrected Mar 23, 2020
0758DMinimal harm, Isolated

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

Corrected Mar 23, 2020
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Mar 23, 2020
0812FMinimal harm, Widespread

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

Nutrition and Dietary Deficiencies

Corrected Mar 23, 2020
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 23, 2020

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Frequently Asked Questions

What is the CareGrader rating for LAKEWOOD POST ACUTE AND REHABILITATION?

LAKEWOOD POST ACUTE AND REHABILITATION in LAKEWOOD, Colorado has a CareGrader grade of C (Average), with a composite score of 75.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for LAKEWOOD POST ACUTE AND REHABILITATION?

LAKEWOOD POST ACUTE AND REHABILITATION has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does LAKEWOOD POST ACUTE AND REHABILITATION have?

LAKEWOOD POST ACUTE AND REHABILITATION has 34 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has LAKEWOOD POST ACUTE AND REHABILITATION been fined?

Yes. LAKEWOOD POST ACUTE AND REHABILITATION has $49,137 in total fines from CMS enforcement actions across 3 penalties.

How many beds does LAKEWOOD POST ACUTE AND REHABILITATION have?

LAKEWOOD POST ACUTE AND REHABILITATION has 108 certified beds with approximately 20 current residents (19% occupancy). The facility is located at 7395 W EASTMAN PL, LAKEWOOD, Colorado 80227. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.