SNF

LAKEWOOD POST ACUTE AND REHABILITATION

CCN: 065400 · LAKEWOOD, CO 80227 · Jefferson County

Overview

Address
7395 W EASTMAN PL, LAKEWOOD, CO 80227
Phone
3037308000
Certified beds
108
Avg daily residents
20 (19% of beds filled)
Ownership
For-profit LLC
Provider type
Medicare
Medicare/Medicaid since
2010-07-16
Setting
Urban
2 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 2/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 2/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
★★★★★ 4/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 4/5
Quality Measures breakdown
Long-Stay Quality Measures — Data not available.
Short-Stay Quality Measures ★★★★★ 4/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 6.65 4.53 5.67 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 1.54 0.79 1.31 ≥ 0.55
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 1.47 1.00 1.25 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 3.64 2.73 3.11 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 3.00 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.24 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
5.93
hrs / resident / day
RN (weekend)
1.06
hrs / resident / day
Total nurse (adjusted, weekend)
5.06
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
58.1%
annual
RN turnover
77.8%
annual
Administrators departed
1
last 12 months

Resident acuity

Nursing Case-Mix Index
1.60
higher acuity than avg
Case-Mix Index Ratio
1.16
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-03-27 11 11 1 56 1 56
Cycle 2/3 (prior) 2023-09-28 13 12 1 144 2 216
Total weighted health score
96.0
lower is better

Deficiencies (34)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

31 D/E/F Actual harm — potential for minor
3 G/H/I Actual harm
Tag Description Scope/Severity Survey date Corrected
0552 Ensure that residents are fully informed and understand their health status, care and treatments. D 2025-03-27 2025-05-09
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2025-03-27 2025-05-09
0658 Ensure services provided by the nursing facility meet professional standards of quality. D 2025-03-27 2025-05-09
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2025-03-27 2025-05-09
0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. D 2025-03-27 2025-05-09
0730 Observe each nurse aide's job performance and give regular training. E 2025-03-27 2025-05-09
0742 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 2025-03-27 2025-05-09
0758 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. D 2025-03-27 2025-05-09
0880 Provide and implement an infection prevention and control program. E 2025-03-27 2025-05-09
0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. E 2025-03-27 2025-05-09
0808 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. D 2025-03-27 2025-05-09
0578 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 2023-09-28 2023-10-22
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2023-09-28 2023-10-22
0658 Ensure services provided by the nursing facility meet professional standards of quality. E 2023-09-28 2023-10-22
0692 Provide enough food/fluids to maintain a resident's health. G 2023-09-28 2023-10-22
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2023-09-28 2023-10-22
0697 Provide safe, appropriate pain management for a resident who requires such services. G 2023-09-28 2023-12-19
0726 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. E 2023-09-28 2023-10-22
0760 Ensure that residents are free from significant medication errors. D 2023-09-28 2023-10-22
0761 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. F 2023-09-28 2023-12-19
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F 2023-09-28 2023-10-22
0880 Provide and implement an infection prevention and control program. E 2023-09-28 2023-10-22
0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. E 2023-09-28 2023-10-22
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. G 2023-04-19 2023-05-19
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. D 2020-02-25 2020-03-23
0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. D 2020-02-25 2020-03-23
0584 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. E 2020-02-25 2020-03-23
0658 Ensure services provided by the nursing facility meet professional standards of quality. D 2020-02-25 2020-03-23
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2020-02-25 2020-03-23
0695 Provide safe and appropriate respiratory care for a resident when needed. E 2020-02-25 2020-03-23
0758 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. D 2020-02-25 2020-03-23
0761 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. E 2020-02-25 2020-03-23
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F 2020-02-25 2020-03-23
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2020-02-25 2020-03-23

Penalties (3)

Fines issued
2
last 3 years
Total fines
$49,137
Payment denials
1
Date Type Fine amount
2023-04-19 Fine $16,624
2023-09-28 Fine $32,513
2023-09-28 Payment Denial —

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Operating performance

Occupancy Rate
8.0%
Cost per Resident Day
$463

Revenue & costs

Net Patient Revenue
$1.1M
Total Costs
$487K
Net Income
-$1.5M

Balance sheet

Total Assets
$1.4M
Total Liabilities
$3.2M
Fund Balance
-$1.8M
Current Ratio
0.38

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: PACS GROUP

Chain ID
690
Facilities in chain
264
Legal business name
EASTMAN COMMUNITY HEALTHCARE LLC
Chain-average star ratings (for peer context)
Overall
2.9
Health
2.6
Staffing
2.4
QM
4.2

Owner / manager organizations (4)

Organization Role Association
PANTHER MASTER TENANT, LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 09/01/2023
PACS GROUP, INC. 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 09/01/2023
PACS HOLDINGS, LLC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 09/01/2023
PROVIDENCE GROUP NH, LLC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 09/01/2023

Owner / manager individuals (8)

Name Role Association
HANCOCK, MARK 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 04/15/2024
MURRAY, JASON 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 04/15/2024
APT, FREDERICK CORPORATE OFFICER since 01/01/2024
HANCOCK, MARK CORPORATE OFFICER since 01/01/2024
JERGENSEN, JOSHUA CORPORATE OFFICER since 01/01/2024
MITCHELL, JOHN CORPORATE OFFICER since 01/01/2024
JAVERY, SHAHID CONTRACTED MANAGING EMPLOYEE since 07/20/2023
BIRRELL, AUSTIN W-2 MANAGING EMPLOYEE since 05/15/2024

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

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Show 110 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $463 metrics.cost_per_resident_day
Cost Report Current Ratio 0.38 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicare Day Share (%) 100.0% metrics.medicare_day_share
Cost Report Net Income ($) $-1,521,905 metrics.net_income
Cost Report Net Patient Revenue ($) $1,107,926 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 8.0% metrics.occupancy_rate
Cost Report Total Assets ($) $1,362,677 metrics.total_assets
Cost Report Total Costs ($) $487,394 metrics.total_costs
Cost Report Total Fund Balances ($) $-1,794,588 metrics.fund_balance
Cost Report Total Liabilities ($) $3,157,265 metrics.total_liabilities
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 1.25010 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 3.10821 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 1.31097 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 5.66929 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 5.06028 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote — Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 20.3 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 1.00457 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.73020 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.79182 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 4.52659 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.98971 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.6 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.9 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 4.2 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 2.4 Chain Average Staffing Rating
Provider Information Chain ID 690 Chain ID
Provider Information Chain Name PACS GROUP Chain Name
Provider Information City/Town LAKEWOOD City/Town
Provider Information CMS Certification Number (CCN) 065400 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Jefferson County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 2010-07-16 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 2 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 39.6583 Latitude
Provider Information Legal Business Name EASTMAN COMMUNITY HEALTHCARE LLC Legal Business Name
Provider Information Location 7395 W EASTMAN PL,LAKEWOOD,CO,80227 Location
Provider Information Long-Stay QM Rating — Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote 2 Long-Stay QM Rating Footnote
Provider Information Longitude -105.08 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 1 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 108 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 264 Number of Facilities in Chain
Provider Information Number of Fines 2 Number of Fines
Provider Information Number of Payment Denials 1 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.60357 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 1.16399 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 2 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type For profit - Limited Liability company Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 7395 W EASTMAN PL Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name LAKEWOOD POST ACUTE AND REHABILITATION Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 290 Provider SSA County Code
Provider Information Provider Type Medicare Provider Type
Provider Information QM Rating 4 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 56 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 1 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 11 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-03-27 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 56 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 11 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 12 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2023-09-28 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 144 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 72 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 1 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 2 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 216 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 13 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 1.06230 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 77.8 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote — Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 3.00263 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 1.46563 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 3.64410 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.24383 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 1.53699 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 6.64673 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 4 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote — Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating 4 Staffing Rating
Provider Information Staffing Rating Footnote — Staffing Rating Footnote
Provider Information State CO State
Provider Information Telephone Number 3037308000 Telephone Number
Provider Information Total Amount of Fines in Dollars 49137.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 5.93272 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 3 Total Number of Penalties
Provider Information Total nursing staff turnover 58.1 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 96.000 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 80227 ZIP Code