Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
THE LODGE AT RED ROCKS
MORRISON, CO · 180 certified beds · Last Life Safety survey January 15, 2026
CMS Certification Number 065188 · first certified April 1982
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
- Ownership changed April 5, 2022 (change of ownership)to BEAR CREEK CENTER from PEAK MEDICAL COLORADO NO. 3, LLC
Position within CO
41 citations — more than 99% 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 15.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens June 2027 — about 9 months from now. This facility’s last Life Safety survey was January 2026. 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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6 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
3 of the 41 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)
12 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 41 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.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 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-0908 Keep all essential equipment working safely.
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 | 41 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 25, 2019 | 10 |
| September 21, 2023 | 21 |
| January 15, 2026 | 10 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 3 | 2026-01-15 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-01-15 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2026-01-15 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2023-09-21 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2023-09-21 |
| 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 | 2023-09-21 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2023-09-21 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2026-01-15 |
What the citations cover
- Smoke Deficiencies 17
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Services Deficiencies 6
- Egress Deficiencies 4
- Other 7
| Category | Citations |
|---|---|
| Smoke Deficiencies | 17 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Services Deficiencies | 6 |
| Egress Deficiencies | 4 |
| Miscellaneous Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 15, 2026 — 10 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. | Deficient, Provider has date of correction (April 29, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 7, 2026) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (April 30, 2026) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (February 25, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 7, 2026) |
| 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 (February 25, 2026) |
| K-0522 | Have an externally vented heating system. | Deficient, Provider has date of correction (July 7, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 19, 2026) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (April 29, 2026) |
| K-0922 | Meet requirements for the use and maintenance of medical gas equipment. | Deficient, Provider has date of correction (April 29, 2026) |
September 21, 2023 — 21 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (October 20, 2023) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (October 20, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (November 13, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (November 30, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Waiver has been granted (November 30, 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. | Waiver has been granted (January 30, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 30, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (May 29, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (November 29, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Waiver has been granted (November 30, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Waiver has been granted (May 29, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 30, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 30, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (May 29, 2024) |
| K-0532 | Have a properly installed and maintained dumbwaiter or escalator. | Waiver has been granted (May 29, 2024) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Waiver has been granted (May 29, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 30, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Waiver has been granted (May 29, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (November 30, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 30, 2023) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (November 30, 2023) |
September 25, 2019 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Waiver has been granted (May 6, 2020) |
| 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 (October 25, 2019) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 23, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (January 31, 2020) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (February 6, 2020) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 9, 2019) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (January 31, 2020) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 29, 2019) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (October 25, 2019) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (December 9, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.