Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MAPLETON POST ACUTE
LAKEWOOD, CO · 90 certified beds · Last Life Safety survey December 5, 2024
CMS Certification Number 065097 · first certified April 1968
Ownership
Operated by THE ENSIGN GROUP · For profit - Corporation
- Ownership changed March 1, 2023 (change of ownership)from MILE HIGH CARE SERVICES LLC
Position within CO
33 citations — more than 91% 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 10 citations; the earlier surveys in the window averaged 11.5. 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: May 2026 to December 2026. This facility’s last Life Safety survey was December 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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7 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 33 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 | 33 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 29, 2019 | 11 |
| June 29, 2023 | 12 |
| December 5, 2024 | 10 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2024-12-05 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-12-05 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 3 | 2024-12-05 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-12-05 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-12-05 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2023-06-29 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2023-06-29 |
| K-0271 | Have exits that are accessible at all times. | 2 | 2023-06-29 |
What the citations cover
- Smoke Deficiencies 13
- Egress Deficiencies 6
- Miscellaneous Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Egress Deficiencies | 6 |
| Miscellaneous Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Services Deficiencies | 4 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 5, 2024 — 10 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 (January 29, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (January 29, 2025) |
| 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 29, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 5, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 29, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 29, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (January 29, 2025) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (February 5, 2025) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (January 29, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 29, 2025) |
June 29, 2023 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Waiver has been granted (September 25, 2023) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (September 25, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 25, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 25, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (September 25, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 25, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (September 25, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (September 25, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 25, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (September 25, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 25, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 25, 2023) |
August 29, 2019 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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. | Waiver has been granted (April 17, 2020) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (October 18, 2019) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (October 18, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 10, 2019) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 18, 2019) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 18, 2019) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 18, 2019) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (October 18, 2019) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 18, 2019) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (November 1, 2019) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 18, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.