Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
CAMBRIDGE CARE CENTER
LAKEWOOD, CO · 110 certified beds · Last Life Safety survey April 2, 2024
CMS Certification Number 065296 · first certified December 1991
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CO
24 citations — more than 75% 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
The latest survey found 9 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (September 2025 to April 2026), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was April 2024. 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.
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 24 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 24 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 24, 2021 | 7 |
| December 15, 2022 | 8 |
| April 2, 2024 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 3 | 2024-04-02 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-04-02 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-04-02 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2022-12-15 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2022-12-15 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2021-08-24 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2021-08-24 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2021-08-24 |
What the citations cover
- Smoke Deficiencies 12
- Services Deficiencies 4
- Egress Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Services Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 2, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (May 9, 2024) |
| 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 (May 16, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 11, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 9, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 8, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (May 11, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (May 13, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (May 10, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (May 29, 2024) |
December 15, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (February 3, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (February 3, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 3, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 2, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (February 3, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (February 3, 2023) |
| K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Deficient, Provider has date of correction (February 3, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 3, 2023) |
August 24, 2021 — 7 citations
| 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 (October 14, 2021) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 16, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 29, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 1, 2021) |
| 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 30, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 1, 2021) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (October 10, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.