Cycle 1
Health 2024-02-27 · Fire 2024-02-27
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lakewood, CO
Western Hills Health Care Center
5-star overall rating with 5-star inspections with 5 recent health deficiencies
1625 Carr St, Lakewood, CO
(303) 232-6881
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1985-04-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
194 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
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
0.76
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,245
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9985
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
6.28
Baseline 49.23% · Performance 38.03% · Measure score 6.28 · Achievement 6.28 · Improvement 4.10
Adjusted total nurse staffing
2.78
Baseline 3.38 hours · Performance 3.87 hours · Measure score 2.78 · Achievement 2.78 · Improvement 1.52
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 11.11% · Lower 95% interval 6.59% |
| Discharge to community | 49.57% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 46.67% · Lower 95% interval 35.84% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 1 · Denominator 25 · Adjusted rate 4.82% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 10.4% |
8.2%
2.2 pts better
|
Numerator 13 · Denominator 125 |
| Staff flu vaccination coverage | 68.35% |
42%
26.3 pts better
|
Numerator 108 · Denominator 158 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.5% |
93.5%
4 pts worse
|
93.4%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.1% · Q2 90.0% · Q3 88.9% · Q4 87.8% · 4Q avg 89.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.3% |
94.7%
5.4 pts worse
|
95.5%
6.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.4%
0.8 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.8% · Q3 2.8% · Q4 2.7% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
7.4%
1.9 pts better
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.6% · Q3 11.4% · Q4 4.3% · 4Q avg 5.5% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.0%
1.1 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.9% · Q3 3.4% · Q4 3.4% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.8% |
11.2%
3.6 pts worse
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 14.5% · Q3 15.3% · Q4 11.5% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.0% |
20.6%
4.6 pts better
|
16.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 14.8% · Q3 15.4% · Q4 17.3% · 4Q avg 16.0% · 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 | 12.3% |
15.2%
2.9 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 18.3% · Q3 4.5% · Q4 11.0% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
14.6%
7.6 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 7.9% · Q3 0.0% · Q4 8.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.8%
1.2 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.4% · Q3 0.0% · Q4 2.9% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.5%
0.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.6% |
22.4%
10.2 pts worse
|
19.8%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.6% · Q2 21.7% · Q3 31.4% · Q4 29.2% · 4Q avg 32.6% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
3.7%
1.6 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.6% · Q3 0.0% · Q4 1.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.7% |
76.4%
0.3 pts better
|
81.7%
5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.1% · Q2 76.2% · Q3 77.2% · Q4 78.6% · 4Q avg 76.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
12.8%
4.8 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 7.1% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 2.4% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.4% |
75.6%
0.2 pts worse
|
79.7%
4.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.9% |
20.3%
15.6 pts worse
|
23.9%
12 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.9% · Observed 32.1% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-10 · Fire 2022-11-10
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-07-13 · Fire 2021-07-13
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-27
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-03-20
D · Potential for more than minimal harm
2022-11-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-29
F · Potential for more than minimal harm
2021-07-13
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 2021-07-29
F · Potential for more than minimal harm
2021-07-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-07-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-07-13
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-07-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-13
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-13
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-13
F849 · Administration Deficiencies
Health
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.
Corrected 2021-07-29
Penalties and ownership
What sits behind the stars
Ownership
Preston, Forrest
5% Or Greater Direct Ownership Interest · Individual
Cross, Cindy
Corporate Officer · Individual
Denzler, Anna
Operational/Managerial Control · Individual
Dergance, Jeannae
Operational/Managerial Control · Individual
Fletcher, Todd
Operational/Managerial Control · Individual
Fletcher, Todd
Corporate Director · Individual
Fletcher, Todd
Corporate Officer · Individual
Henry, Terry
Corporate Officer · Individual
Lay, Lisa
Operational/Managerial Control · Individual
Lay, Lisa
Corporate Director · Individual
Lay, Lisa
Corporate Officer · Individual
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Linenberger, Charity
Operational/Managerial Control · Individual
Preston, Aubrey
Operational/Managerial Control · Individual
Preston, Forrest
Operational/Managerial Control · Individual
Preston, Forrest
Corporate Director · Individual
Preston, Forrest
Corporate Officer · Individual
Schmidt, Derek
Operational/Managerial Control · Individual
Swanker, Richard
Operational/Managerial Control · Individual
Swanker, Richard
Corporate Director · Individual
Swanker, Richard
Corporate Officer · Individual
Thurmond, Joan
Corporate Officer · Individual
Ziegler, James
Operational/Managerial Control · Individual
Ziegler, James
Corporate Director · Individual
Ziegler, James
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Allison Care Center
Lakewood, CO
2-star overall rating with 2-star inspections with abuse icon flag with $34,580 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Harmony Pointe Care Center
Lakewood, CO
3-star overall rating with 2-star inspections with $1,576 in total fines with 17 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Cedars Healthcare Center
Lakewood, CO
1-star overall rating with 1-star inspections with $31,663 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out