Lakewood, CO

Sierra Post Acute

2-star overall rating with 1-star inspections with abuse icon flag with $12,874 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

1432 Depew St, Lakewood, CO

(303) 238-1375

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

102

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pacs Group

Operator or chain grouping

Approved since

1990-03-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

264 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.53

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.80

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

2.05

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.38

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.33

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

2.83

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.32

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.12

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.69

CMS adjusted RN staffing hours

Adjusted total hours

4.39

CMS adjusted total nurse staffing hours

Case-mix index

1.05

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,196

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

21.18

Composite VBP score used to determine payment impact.

Payment multiplier

0.9826

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

Baseline 31.25% · Performance 65.28% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

4.24

Baseline 4.26 hours · Performance 4.28 hours · Measure score 4.24 · Achievement 4.24 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	11.65%	8.2% 3.5 pts better	Numerator 12 · Denominator 103
Staff flu vaccination coverage	92.37%	42% 50.4 pts better	Numerator 121 · Denominator 131
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	1.3 0.1 pts better	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	1.7 0.2 pts better	1.8 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.7 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	87.7%	93.5% 5.8 pts worse	93.4% 5.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 87.2% · Q2 82.0% · Q3 83.1% · Q4 98.9% · 4Q avg 87.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	94.7% 5.3 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.3%	3.4% 1.1 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.2% · Q3 3.4% · Q4 2.3% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	7.4% 7.4 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	1.3%	5.0% 3.7 pts better	5.4% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 3.8% · Q4 0.0% · 4Q avg 1.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	12.9%	11.2% 1.7 pts worse	19.6% 6.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 10.5% · Q3 12.7% · Q4 14.1% · 4Q avg 12.9%
Percentage of long-stay residents who received an antipsychotic medication	44.4%	20.6% 23.8 pts worse	16.7% 27.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 47.1% · Q3 46.9% · Q4 42.1% · 4Q avg 44.4% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	14.6%	15.2% 0.6 pts better	16.3% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 15.9% · Q3 24.8% · Q4 3.5% · 4Q avg 14.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.2%	14.6% 1.6 pts worse	14.9% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 17.1% · Q3 27.8% · Q4 2.6% · 4Q avg 16.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.8% 0.8 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.1%	1.5% 0.4 pts better	1.7% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.0%	22.4% 7.4 pts better	19.8% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 20.6% · Q3 9.4% · Q4 17.3% · 4Q avg 15.0%
Percentage of long-stay residents with pressure ulcers	0.9%	3.7% 2.8 pts better	5.1% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	61.8%	76.4% 14.6 pts worse	81.7% 19.9 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 61.8%

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-10-24 · Fire 2023-10-24

14 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2022-09-15 · Fire 2022-09-15

17 health deficiencies

Top issue: Quality of Life and Care (11 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-06-10 · Fire 2021-06-10

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-10-24

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2023-11-17

Inspection history

Recent health citations

G · Actual harm 2026-01-29

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2026-02-07

F · Potential for more than minimal harm 2026-01-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-02-04

D · Potential for more than minimal harm 2026-01-29

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2026-02-09

G · Actual harm 2025-10-20

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-11-13

D · Potential for more than minimal harm 2025-02-26

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-03-17

J · Immediate jeopardy 2024-09-05

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-08-21

F · Potential for more than minimal harm 2024-03-20

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-04-07

E · Potential for more than minimal harm 2024-03-20

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-04-07

G · Actual harm 2023-10-24

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-17

F · Potential for more than minimal harm 2023-10-24

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2023-11-17

F · Potential for more than minimal harm 2023-10-24

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2023-11-17

F · Potential for more than minimal harm 2023-10-24

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-10-24

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-10-24

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-10-24

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-10-24

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-24

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-24

F691 · Quality of Life and Care Deficiencies

Health

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Corrected 2023-12-13

D · Potential for more than minimal harm 2023-10-24

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-24

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-11-17

G · Actual harm 2023-05-04

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-05-06

G · Actual harm 2022-09-15

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2022-09-22

G · Actual harm 2022-09-15

F692 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-09-22

E · Potential for more than minimal harm 2022-09-15

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2022-09-22

E · Potential for more than minimal harm 2022-09-15

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2022-09-22

E · Potential for more than minimal harm 2022-09-15