Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Edgewater Health and Rehabilitation
LAKEWOOD, CO · 67 certified beds · Last Life Safety survey August 27, 2025
CMS Certification Number 065171 · first certified December 1981
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
17 citations — more than 51% 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 4 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens February 2027 — about 4 months from now. This facility’s last Life Safety survey was August 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.
Physical environment (health survey)
2 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 17 Life Safety citations above. The Physical Environment Index
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 | 17 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 3, 2022 | 9 |
| February 14, 2024 | 4 |
| August 27, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-08-27 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-02-14 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2024-02-14 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2025-08-27 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-02-14 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2024-02-14 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2022-11-03 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2025-08-27 |
What the citations cover
- Smoke Deficiencies 11
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Services Deficiencies 2
- Egress Deficiencies 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Services Deficiencies | 2 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 27, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (October 22, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 22, 2025) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (October 22, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 22, 2025) |
February 14, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 (March 26, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 26, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 26, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 26, 2024) |
November 3, 2022 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 16, 2022) |
| 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 (December 22, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 16, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 27, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (March 1, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 16, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 16, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 31, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 16, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.