Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
CEDARS HEALTHCARE CENTER
LAKEWOOD, CO · 130 certified beds · Last Life Safety survey March 19, 2024
CMS Certification Number 065202 · first certified December 1984
Ownership
Operated by STELLAR SENIOR LIVING · For profit - Limited Liability company
- Ownership changed January 1, 2020 (change of ownership)from FIVE STAR QUALITY CARE-COLORADO LLC
Position within CO
27 citations — more than 82% 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 6 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?
Well past the typical window (August 2025 to March 2026), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was March 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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5 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
4 of the 27 citations on file are 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
Physical environment (health survey)
7 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 27 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 | 27 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 18, 2021 | 13 |
| December 1, 2022 | 8 |
| March 19, 2024 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-03-19 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-03-19 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2024-03-19 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-03-19 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-03-19 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2021-08-18 |
| K-0930 | Ensure proper storage of liquid oxygen. | 1 | 2021-08-18 |
| E-0030 | List the names and contact information of those in the facility. | 1 | 2021-08-18 |
What the citations cover
- Smoke Deficiencies 11
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Emergency Preparedness Deficiencies 4
- Services Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Emergency Preparedness Deficiencies | 4 |
| Services Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
| Construction Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 19, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 11, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 21, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 11, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (May 21, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 11, 2024) |
December 1, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (December 28, 2022) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 28, 2022) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (January 16, 2023) |
| 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 (January 16, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 16, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 16, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 16, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (January 16, 2023) |
August 18, 2021 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (September 17, 2021) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (September 17, 2021) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (September 24, 2021) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 8, 2021) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 23, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 23, 2021) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (October 8, 2021) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (September 28, 2021) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (October 8, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 24, 2021) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (September 24, 2021) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 8, 2021) |
| K-0930 | Ensure proper storage of liquid oxygen. | Deficient, Provider has date of correction (October 8, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.