01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-27 | 11 | 2025-03-27 | 2 |
| Cycle 2 | 2023-09-28 | 12 | 2023-09-28 | 10 |
| Cycle 3 | 2020-02-25 | 10 | 2020-02-25 | 11 |
CMS CCN 0654002026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Lakewood Post Acute And Rehabilitation
7395 W Eastman Pl · Lakewood, CO 80227 · Jefferson County
Certified beds108CMS provider file
Recent citation rows56current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
56 rows in the current release
2 rows carry G–L scope/severity codes; 0 carry J–L. 11 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-03-27 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2025-05-092025-03-27 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-05-092025-03-27 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-05-092025-03-27 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-05-092025-03-27 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-05-092025-03-27 · HEALTHF0730Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2025-05-092025-03-27 · HEALTHF0742Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-092025-03-27 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-092025-03-27 · HEALTHF0808Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-09 · complaint2025-03-27 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-05-092025-03-27 · HEALTHF0943Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Correction field: Deficient, Provider has date of correction · 2025-05-092025-03-27 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has plan of correction · 2025-04-242025-03-27 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-04-242023-09-28 · FIREE0001Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2023-10-222023-09-28 · HEALTHF0578Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-10-222023-09-28 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-10-222023-09-28 · HEALTHF0658Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2023-10-222023-09-28 · HEALTHF0692Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2023-10-222023-09-28 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2023-10-222023-09-28 · HEALTHF0697Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2023-12-192023-09-28 · HEALTHF0726Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-10-222023-09-28 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2023-10-222023-09-28 · HEALTHF0761Severity F · widespread; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-12-192023-09-28 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-10-2203 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2023-09-28 | Fine | $32,513 | 0 |
| 2023-09-28 | Payment Denial | $0 | 53 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PANTHER MASTER TENANT, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 09/01/2023
- PROVIDENCE GROUP NH, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 09/01/2023
- JAVERY, SHAHIDIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 07/20/2023
- BIRRELL, AUSTINIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 05/15/2024
- APT, FREDERICKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2024
- HANCOCK, MARKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2024
- JERGENSEN, JOSHUAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2024
- MITCHELL, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours6.95per resident day
RN hours2.00per resident day
Weekend nurse hours5.78per resident day
Staff turnover44.7%CMS reported field
06 / LOCAL RECORDS
Open the Lakewood ledger →Other published facilities nearby
Ahc Of Lakewood, Llc36 beds · CMS overall 5/524 citation rowsAllison Care Center85 beds · CMS overall 2/525 citation rowsCambridge Care Center110 beds · CMS overall 3/541 citation rowsCedars Healthcare Center130 beds · CMS overall 3/570 citation rowsEdgewater Health And Rehabilitation67 beds · CMS overall 5/529 citation rowsHarmony Pointe Care Center125 beds · CMS overall 3/557 citation rowsLakewood Villa57 beds · CMS overall 4/542 citation rowsMapleton Post Acute90 beds · CMS overall 4/561 citation rows