Federal inspection record · CMS data as of October 1, 2026
Lakewood Post Acute And Rehabilitation
7395 W Eastman Pl, Lakewood, CO · (303) 730-8000
- Certified beds
- 108
- Residents per day
- 24
- Ownership
- For-Profit
- Chain
- Pacs Group
- Medicare / Medicaid
- Medicare
- Certified since
- July 16, 2010
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Colorado.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Colorado homes
Lakewood Post Acute And Rehabilitation carries 88.5 inspection points. That is fewer than 31% of Colorado's 208 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Colorado: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–22 pts
- 4★ 22–44 pts
- 3★ 44–70.75 pts
- 2★ 70.75–104 pts
- 1★ over 104 pts
Bars show every rated home in Colorado by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
33 health citations on record since 2020. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
G
Provide enough food/fluids to maintain a resident's health.
-
G
Provide safe, appropriate pain management for a resident who requires such services.
Everything else, by area of care
Resident Assessment and Care Planning6E
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Quality of Life and Care6E
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
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.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Rights5E
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
- E
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.
- E
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.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Pharmacy Service5F
- D
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.
- F
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.
- D
Ensure that residents are free from significant medication errors.
- E
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.
- D
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.
Infection Control3E
- E
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Nutrition and Dietary3F
- D
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.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nursing and Physician Services2E
- E
Observe each nurse aide's job performance and give regular training.
- E
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.
Freedom from Abuse, Neglect, and Exploitation1E
- E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspection history
2025-03-27
11 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2023-09-28
12 health deficiencies · 10 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2020-02-25
10 health deficiencies · 11 fire-safety deficiencies
Top issue: Resident Rights (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 5 h 28 min of nursing staff time a day, 1 h 19 min of it from a registered nurse.
This home
5 h 28 min
Colorado average
3 h 42 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 43% of nursing staff and 73% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine9.3 pts better | 86.3% | 77.0% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit0.4 pts better | 11.6% | 12.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.3 pts better | 1.3% | 1.6% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine16.5 pts better | 90.1% | 73.6% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission9.3 pts better | 11.2% | 20.5% | 23.4% |
·
Who owns and runs it
8 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Panther Master Tenant, LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 9 facilities |
| Providence Group Nh, LLC | 5% Or Greater Indirect Ownership Interest · Organization | 100% | 76 facilities |
| Apt, Frederick | Corporate Officer · Individual | 0% | 258 facilities |
| Birrell, Austin | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Hancock, Mark | Corporate Officer · Individual | 0% | 159 facilities |
| Javery, Shahid | Contracted Managing Employee · Individual | 0% | 1 facilities |
| Jergensen, Joshua | Corporate Officer · Individual | 0% | 262 facilities |
| Mitchell, John | Corporate Officer · Individual | 0% | 276 facilities |
·
Fire safety
23 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke6F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Install corridor and hallway doors that block smoke.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Inspect, test, and maintain automatic sprinkler systems.
Services5F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F
Have properly installed electrical wiring and gas equipment.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F
Have an externally vented heating system.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Miscellaneous4F
- F
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
- D
Have restrictions on the use of flammable curtains.
Gas, Vacuum, and Electrical Systems4F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Meet requirements for the installation and maintenance of electrical systems.
Egress3F
- F
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.
- F
Install emergency lighting that can last at least 1 1/2 hours.
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Emergency Preparedness1F
- F
Establish an Emergency Preparedness Program (EP).
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Other homes nearby
-
Hallmark Nursing Center
Denver, CO · Life Care Centers Of America
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 37 min
- Fines
- $6,788
-
Heights Care & Rehabilitation LLC
Denver, CO · Pacs Group
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 34 min
- Fines
- $68,159
-
Villa Manor Care Center
Lakewood, CO · Life Care Centers Of America
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h
- Fines
- $0