Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
CHERRELYN HEALTHCARE CENTER
LITTLETON, CO · 190 certified beds · Last Life Safety survey January 30, 2025
CMS Certification Number 065203 · first certified December 1984
Ownership
Operated by STELLAR SENIOR LIVING · For profit - Corporation
- Ownership changed January 1, 2020 (change of ownership)from FIVE STAR QUALITY CARE-COLORADO LLC
Position within CO
37 citations — more than 95% 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 8 citations; the earlier surveys in the window averaged 14.5. 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: July 2026 to February 2027. This facility’s last Life Safety survey was January 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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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.
Emergency preparedness
1 of the 37 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
Physical environment (health survey)
4 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 37 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 | 37 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 15, 2022 | 18 |
| August 16, 2023 | 11 |
| January 30, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-01-30 |
| K-0324 | Provide properly protected cooking facilities. | 3 | 2025-01-30 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-01-30 |
| 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. | 2 | 2025-01-30 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2023-08-16 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-01-30 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2025-01-30 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2025-01-30 |
What the citations cover
- Smoke Deficiencies 16
- Egress Deficiencies 7
- Services Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 16 |
| Egress Deficiencies | 7 |
| Services Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 30, 2025 — 8 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 (August 30, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (April 1, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 15, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (August 30, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (August 30, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 1, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 15, 2025) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (April 1, 2025) |
August 16, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 27, 2023) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (November 15, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 15, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 15, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 15, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 15, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 15, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (February 29, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Waiver has been granted (February 29, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (November 15, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 15, 2023) |
June 15, 2022 — 18 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 (July 15, 2022) |
| 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 (July 25, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 24, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 25, 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 (August 14, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 24, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 24, 2022) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (August 24, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 24, 2022) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (August 24, 2022) |
| K-0522 | Have an externally vented heating system. | Deficient, Provider has date of correction (July 25, 2022) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (August 24, 2022) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (July 15, 2022) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 25, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 25, 2022) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (July 25, 2022) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (August 24, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 24, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.