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
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing
LPN hours / resident day
0.86
Licensed practical nurse staffing
Aide hours / resident day
2.08
Nurse aide staffing
Weekend hours
3.26
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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