Cycle 1
Health 2024-04-02 · Fire 2024-04-02
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Lakewood, CO
Cambridge Care Center
4-star overall rating with 3-star inspections with $8,151 in total fines with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1685 Eaton St, Lakewood, CO
(303) 232-4405
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vivage Senior Living
Operator or chain grouping
Approved since
1991-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 3 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.80
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.03
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
3.57
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,693
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.93
Baseline 18.75% · Performance 47.62% · Measure score 3.93 · Achievement 3.93 · Improvement 0
Adjusted total nurse staffing
2.47
Baseline 3.62 hours · Performance 3.78 hours · Measure score 2.47 · Achievement 2.47 · Improvement 0.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.82% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 6.27% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.6 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 11.43% |
8.2%
3.2 pts better
|
Numerator 12 · Denominator 105 |
| Staff flu vaccination coverage | 87.5% |
42%
45.5 pts better
|
Numerator 91 · Denominator 104 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
93.5%
4.4 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.8% · Q3 96.6% · Q4 97.5% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.7%
4.2 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.4%
0.7 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 3.4% · Q4 2.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.8% |
7.4%
1.6 pts better
|
11.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.9% · Q3 7.4% · Q4 9.1% · 4Q avg 5.8% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.0%
1.1 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.2% · Q3 6.2% · Q4 1.4% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.1% |
11.2%
3.1 pts better
|
19.6%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 7.8% · Q3 7.4% · Q4 9.7% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.7% |
20.6%
12.1 pts worse
|
16.7%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 36.2% · Q3 33.3% · Q4 29.8% · 4Q avg 32.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 2.3% |
15.2%
12.9 pts better
|
16.3%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.0% |
14.6%
8.6 pts better
|
14.9%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 10.7% · Q3 6.4% · Q4 0.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.5%
1.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
22.4%
9.1 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 18.2% · Q3 5.5% · Q4 10.7% · 4Q avg 13.3% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
3.7%
0.6 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.8% · Q3 5.1% · Q4 2.6% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.4% |
76.4%
3 pts worse
|
81.7%
8.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.6% · Q2 91.7% · Q3 65.2% · Q4 57.6% · 4Q avg 73.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.2% |
1.5%
3.7 pts worse
|
1.6%
3.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 7.1% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.8% |
75.6%
14.2 pts better
|
79.7%
10.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-15 · Fire 2022-12-15
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-08-24 · Fire 2021-08-24
2 health deficiencies
Top issue: Environmental (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-09
F · Potential for more than minimal harm
2024-04-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-08
F · Potential for more than minimal harm
2024-04-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-13
F · Potential for more than minimal harm
2024-04-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-10
F · Potential for more than minimal harm
2024-04-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-04-02
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-04-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-04-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-11
E · Potential for more than minimal harm
2024-04-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-11
F · Potential for more than minimal harm
2022-12-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-02
F · Potential for more than minimal harm
2022-12-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-15
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-03
D · Potential for more than minimal harm
2022-12-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-02-03
F · Potential for more than minimal harm
2021-08-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-11-30
F · Potential for more than minimal harm
2021-08-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-08-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-10-14
D · Potential for more than minimal harm
2021-08-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-11-16
D · Potential for more than minimal harm
2021-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-29
D · Potential for more than minimal harm
2021-08-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-01
D · Potential for more than minimal harm
2021-08-24
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-10-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-02-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-12
D · Potential for more than minimal harm
2024-08-21
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-08-22
G · Actual harm
2024-04-02
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-04-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-04-02
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-04-02
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-04-02
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-04-03
E · Potential for more than minimal harm
2022-12-15
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-01-09
E · Potential for more than minimal harm
2022-12-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-01-09
E · Potential for more than minimal harm
2022-12-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-14
E · Potential for more than minimal harm
2022-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-09
D · Potential for more than minimal harm
2022-12-15
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-01-09
D · Potential for more than minimal harm
2022-12-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-09
E · Potential for more than minimal harm
2021-08-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-09-09
E · Potential for more than minimal harm
2021-08-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-09-09
Penalties and ownership
What sits behind the stars
$8,151
2024-04-02
Fine
Fine · fine $8,151
Fine
Ownership
Nearby options
Other facilities in reach
#1
Edgewater Health and Rehabilitation
Lakewood, CO
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Cedars Healthcare Center
Lakewood, CO
1-star overall rating with 1-star inspections with $31,663 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Sierra Post Acute
Lakewood, CO
2-star overall rating with 1-star inspections with abuse icon flag with $12,874 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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