Sierra Post Acute
1432 Depew St, Lakewood, CO 80214 · Jefferson County · 102 certified beds · avg 83 residents/day · certified since Mar 1, 1990
Abuse citation flag (CMS)
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 5, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 21, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Jan 29, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 7, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 20, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 13, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 24, 2023 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 17, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 15, 2022 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 22, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 15, 2022 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 22, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (39)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 29, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 29, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 29, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 29, 2026 | E · Potential for harm, repeated | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Jan 29, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 29, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Oct 20, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Feb 26, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 5, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 20, 2024 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Mar 20, 2024 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Oct 24, 2023 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Oct 24, 2023 | F · Potential for harm, facility-wide | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Oct 24, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Oct 24, 2023 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Oct 24, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Oct 24, 2023 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Oct 24, 2023 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Oct 24, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Oct 24, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. |
| Oct 24, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Oct 24, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Oct 24, 2023 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 15, 2022 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 15, 2022 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Sep 15, 2022 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Sep 15, 2022 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Sep 15, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 15, 2022 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Sep 15, 2022 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Sep 15, 2022 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Sep 15, 2022 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 15, 2022 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Sep 15, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Sep 15, 2022 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
| Sep 15, 2022 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 13 | 2 | G ▲ |
| 2023 | 12 | 1 | G ▲ |
| 2024 | 3 | 1 | J ▲ |
| 2025 | 2 | 1 | G ▲ |
| 2026 | 9 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $54,903, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jan 29, 2026 | Fine | $18,428 |
| Oct 20, 2025 | Fine | $26,117 |
| Sep 5, 2024 | Fine | $10,358 |
| Oct 24, 2023 | Payment Denial | 21 days from Nov 22, 2023 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.08 | 3.89 | 3.95 | top 10% in Colorado; top 12% in the U.S. |
| Registered Nurse hours | 0.55 | 0.86 | 0.69 | bottom 18% in Colorado; bottom 45% in the U.S. |
| Weekend total nurse staffing | 4.49 | 3.44 | 3.50 | top 11% in Colorado; top 12% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.36 | 0.61 | 0.48 | bottom 17% in Colorado; bottom 44% in the U.S. |
| Total nursing staff turnover (%) | 50.0 | 47.1 | 45.8 | bottom 41% in Colorado; bottom 38% in the U.S. |
| RN turnover (%) | 54.5 | 44.6 | 42.9 | bottom 29% in Colorado; bottom 29% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.80, RN 0.41, weekend 3.35. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Centennial Master Tenant, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 10/11/2022 |
| Providence Group NH, LLC | Organization | 5% or Greater Indirect Ownership Interest | 100% | 06/30/2023 |
| Apt, Frederick | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Eberhard, Jarom | Individual | W-2 Managing Employee | NOT APPLICABLE | 04/08/2024 |
| Hancock, Mark | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Horton, Christopher | Individual | Contracted Managing Employee | NOT APPLICABLE | 02/01/2023 |
| Jergensen, Joshua | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Mitchell, John | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How can my family member make private phone or video calls, and can we see where?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Cedars Healthcare Center | 0.2 mi | Lakewood, CO | ★★★☆☆ | 2/5 | |
| Edgewater Health and Rehabilitation | 0.3 mi | Lakewood, CO | ★★★★★ | 4/5 | |
| Cambridge Care Center | 0.3 mi | Lakewood, CO | ★★★☆☆ | 2/5 | abuse |
| Harmony Pointe Care Center | 1.1 mi | Lakewood, CO | ★★★☆☆ | 2/5 | |
| Wheatridge Care Center | 1.4 mi | Wheat Ridge, CO | ★★★☆☆ | 2/5 | |
| Mapleton Post Acute | 1.4 mi | Lakewood, CO | ★★★★☆ | 3/5 | |
| Oakwood Care and Rehabilitation | 1.5 mi | Lakewood, CO | ★☆☆☆☆ | 1/5 | abuse |
| Western Hills Health Care Center | 1.6 mi | Lakewood, CO | ★★★☆☆ | 3/5 | |
| Allison Care Center | 1.6 mi | Lakewood, CO | ★★☆☆☆ | 2/5 | abuse |
| Sloan's Lake Rehabilitation Center | 1.6 mi | Denver, CO | ★★★★★ | 5/5 | |
| Rehabilitation Center at Sandalwood, the | 2.1 mi | Wheat Ridge, CO | ★★★★☆ | 3/5 | |
| Lakeside Post Acute | 2.1 mi | Wheat Ridge, CO | ★★★☆☆ | 2/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 065272.