Your report for Sierra Post Acute
Overall Score
CMS Five-Star Quality RatingBelow averageCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- ColoradoAbove only 14% of peers208 rated homes · average 3.1★
- Jefferson CountyAbove only 14% of peers23 rated homes · average 3.0★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.7 vs CO avg
- StaffingCan add or remove a star4★+0.9 vs CO avg
- Quality measuresCan add or remove a star5★+0.8 vs CO avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
- Standard inspection overdueThe most recent standard health inspection is older than CMS expects, so the health inspection rating may not reflect current conditions.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCO avg2.7★U.S. avg2.8★
What is health inspection rating?
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
Why it matters
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 57% of peersCO avg3.1★U.S. avg2.9★
What is staffing rating?
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
Why it matters
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 50% of peersCO avg4.2★U.S. avg3.6★
What is quality measures rating?
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
Why it matters
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.38hrsAbove only 44% of peersCO avg3.73Benchmark4.10
What is total nurse hours?
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Why it matters
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.53hrsAbove only 15% of peersCO avg0.83Benchmark0.75
What is rn hours?
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
Why it matters
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better50%Above only 46% of peersCO avg49%RN turnover46%
What is nursing staff turnover?
The share of nursing staff who left within the past year, from the same payroll data.
Why it matters
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$12,874Above only 47% of peersCO avg$25,587Fines · denials2 · 1
What is fines in the last three years?
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Why it matters
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cycles34citations
8inspection dates
6actual harm (G–I)
1immediate jeopardy (J–L)
Oct 20, 2025most recent
Citations by monthJun 2021 – Oct 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Oct 20, 2025Cycle 1worst G · actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Nov 13, 2025
Feb 26, 2025Cycle 1worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 17, 2025
Sep 5, 2024Cycle 2worst J · immediate jeopardy$10,358
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Aug 21, 2024
Mar 20, 2024Cycle 2worst F · no actual harm
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Apr 7, 2024
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Apr 7, 2024
Oct 24, 2023Cycle 1worst G · actual harmpayment denial
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Nov 17, 2023
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Nov 17, 2023
- F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Nov 17, 2023
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Nov 17, 2023
- F584Honor 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.Resident RightsE · patternCorrected Nov 17, 2023
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Nov 17, 2023
- F727Have 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.Nursing and Physician ServicesF · widespreadCorrected Nov 17, 2023
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareE · patternCorrected Nov 17, 2023
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Nov 17, 2023
- F585Honor 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.Resident RightsF · widespreadCorrected Nov 17, 2023
- F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Nov 17, 2023
- F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Dec 13, 2023
May 4, 2023Cycle 3worst G · actual harm$2,516
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected May 6, 2023
Sep 15, 2022Cycle 2worst G · actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 22, 2022
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Sep 22, 2022
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 22, 2022
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Sep 22, 2022
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Sep 22, 2022
- F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Sep 22, 2022
- F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Sep 22, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Sep 22, 2022
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Sep 22, 2022
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Sep 22, 2022
- F742Provide 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.Quality of Life and CareD · isolatedCorrected Sep 22, 2022
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Sep 22, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Sep 22, 2022
Jun 10, 2021Cycle 3worst G · actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected May 6, 2021
- F688Provide 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.Quality of Life and CareD · isolatedCorrected Jul 23, 2021
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jul 27, 2021
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.38hrs
- Registered nursesRN hours only0.53hrs
- Licensed practical nursesLPN hours0.80hrs
- Nurse aidesCNA hours2.05hrs
- Weekend nursingAll staff on Saturdays and Sundays2.83hrs
- Colorado average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better50%Above only 46% of peersCO avg 49%
- RN turnoverRegistered nurses only46%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy102 certified beds · ~86 residents a day84%Above 55% of peersCO avg 79%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $12,874In fines
- 2Fines
- 1Payment denial
- $25,587CO avg in fines
Above only 47% of peersFewer fines than 47% of rated homes in Colorado
Actions on record
- Sep 5, 2024Civil money penalty$10,358
- Oct 24, 2023Denial of payment for new admissionsfrom Nov 22, 2023
- May 4, 2023Civil money penalty$2,516
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Pacs Group254 facilities in the chain2.9★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Direct owners (5%+)
- Centennial Master Tenant, LLC
Indirect owners (5%+)
- Pacs Group, INC.
- Pacs Holdings, LLC
- Providence Group Nh, LLC
- Mark Hancock
- Jason Murray
Corporate officers
- Frederick Apt
- Mark Hancock
- Joshua Jergensen
- John Mitchell
Contracted managers
- Christopher Horton
Managing employees
- Jarom Eberhard
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 065272 · 1432 DEPEW ST, LAKEWOOD, CO, 80214.
- Percentiles compare this facility with every rated nursing home in Colorado and Jefferson County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
