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 point2★−0.7 vs CO avg
- StaffingCan add or remove a star4★+0.9 vs CO avg
- Quality measuresCan add or remove a star4★−0.2 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.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 20% of 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 assessments4★Above only 22% 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 staff6.65hrsTop 1%CO 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 only1.54hrsTop 4%CO 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 better58%Above only 26% of peersCO avg49%RN turnover78%
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$49,137Above only 16% 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
4inspection dates
3actual harm (G–I)
0immediate jeopardy (J–L)
Mar 27, 2025most recent
Citations by monthFeb 2020 – Mar 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.
Mar 27, 2025Cycle 1worst E · no actual harm
- F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected May 9, 2025
- F808Ensure 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.Nutrition and DietaryD · isolatedCorrected May 9, 2025
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected May 9, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected May 9, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected May 9, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 9, 2025
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 9, 2025
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected May 9, 2025
- 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 May 9, 2025
- 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 May 9, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 9, 2025
Sep 28, 2023Cycle 2worst G · actual harm$32,513, payment denial
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Oct 22, 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 ServiceF · widespreadCorrected Dec 19, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 22, 2023
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Oct 22, 2023
- F578Honor 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.Resident RightsE · patternCorrected Oct 22, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Oct 22, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Oct 22, 2023
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Oct 22, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Oct 22, 2023
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareG · isolatedCorrected Dec 19, 2023
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected Oct 22, 2023
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Oct 22, 2023
Apr 19, 2023Cycle 3worst G · actual harm$16,624
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareG · isolatedCorrected May 19, 2023
Feb 25, 2020Cycle 3worst F · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 23, 2020
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Mar 23, 2020
- F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Resident RightsD · isolatedCorrected Mar 23, 2020
- 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 Mar 23, 2020
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Mar 23, 2020
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Mar 23, 2020
- 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 Mar 23, 2020
- 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 ServiceE · patternCorrected Mar 23, 2020
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 23, 2020
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Mar 23, 2020
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined6.65hrs
- Registered nursesRN hours only1.54hrs
- Licensed practical nursesLPN hours1.47hrs
- Nurse aidesCNA hours3.64hrs
- Weekend nursingAll staff on Saturdays and Sundays5.93hrs
- Colorado average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better58%Above only 26% of peersCO avg 49%
- RN turnoverRegistered nurses only78%Not ranked by CMS
- Administrators who leftIn the past year1Leadership changed
- Occupancy108 certified beds · ~20 residents a day19%Lowest tier among peersCO avg 79%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $49,137In fines
- 2Fines
- 1Payment denial
- $25,587CO avg in fines
Above only 16% of peersFewer fines than 16% of rated homes in Colorado
Actions on record
- Sep 28, 2023Civil money penalty$32,513
- Sep 28, 2023Denial of payment for new admissionsfrom Oct 27, 2023
- Apr 19, 2023Civil money penalty$16,624
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Pacs Group254 facilities in the chain2.9★ chain average
- Certification
- Medicare
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Direct owners (5%+)
- Panther 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
- Shahid Javery
Managing employees
- Austin Birrell
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 065400 · 7395 W EASTMAN PL, LAKEWOOD, CO, 80227.
- 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.
