Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

LAKEWOOD POST ACUTE AND REHABILITATION

LAKEWOOD, CO · 108 certified beds · Last Life Safety survey March 27, 2025

CMS Certification Number 065400 · first certified July 2010

Ownership

Operated by PACS GROUP · For profit - Limited Liability company

Ownership changed September 1, 2023 (change of ownership)from 7395 W EASTMAN PLACE OPERATIONS II LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within CO

23 citations — more than 68% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 2 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: September 2026 to April 2027. This facility’s last Life Safety survey was March 2025. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 23 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

E-0001

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-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.

How that compares

Citations on file over three years

Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	23
Median facility in CO	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
February 25, 2020	11
September 28, 2023	10
March 27, 2025	2

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0712	Have simulated fire drills held at unexpected times.	3	2025-03-27
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	3	2025-03-27
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2023-09-28
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2023-09-28
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	1	2020-02-25
K-0927	Have proper fire barriers, ventilation and signs for the transfilling of oxygen.	1	2023-09-28
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	1	2023-09-28
K-0911	Meet requirements for the installation and maintenance of electrical systems.	1	2020-02-25

What the citations cover

Citations by CMS category

Smoke Deficiencies 6
Services Deficiencies 5
Gas, Vacuum, and Electrical Systems Deficiencies 4
Miscellaneous Deficiencies 4
Other 4

Citations by CMS category
Category	Citations
Smoke Deficiencies	6
Services Deficiencies	5
Gas, Vacuum, and Electrical Systems Deficiencies	4
Miscellaneous Deficiencies	4
Egress Deficiencies	3
Emergency Preparedness Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 27, 2025 — 2 citations

Citations issued on March 27, 2025
Tag	What the surveyor checks	Status
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has plan of correction (April 24, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (April 24, 2025)

September 28, 2023 — 10 citations

Citations issued on September 28, 2023
Tag	What the surveyor checks	Status
E-0001	Establish an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (October 22, 2023)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (November 1, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (November 27, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (November 27, 2023)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (November 27, 2023)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (November 27, 2023)
K-0522	Have an externally vented heating system.	Deficient, Provider has date of correction (October 26, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (October 31, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (November 27, 2023)
K-0927	Have proper fire barriers, ventilation and signs for the transfilling of oxygen.	Deficient, Provider has date of correction (November 27, 2023)

February 25, 2020 — 11 citations

Citations issued on February 25, 2020
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (September 14, 2020)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (September 16, 2020)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (September 14, 2020)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 16, 2020)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (September 23, 2020)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (October 13, 2020)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (October 18, 2020)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (October 14, 2020)
K-0751	Have restrictions on the use of flammable curtains.	Deficient, Provider has date of correction (October 16, 2020)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (September 5, 2020)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (September 14, 2020)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.