Cycle 1
Health 2024-03-19 · Fire 2024-03-19
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lakewood, CO
Cedars Healthcare Center
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
1599 Ingalls St, Lakewood, CO
(303) 232-3551
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stellar Senior Living
Operator or chain grouping
Approved since
1984-12-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing
LPN hours / resident day
0.83
Licensed practical nurse staffing
Aide hours / resident day
1.81
Nurse aide staffing
Weekend hours
3.02
Weekend nurse staffing
RN turnover
18%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
93.5%
5.2 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.7%
3.4 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.4%
0.5 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
7.4%
6.8 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.0%
2.4 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.4% |
11.2%
3.2 pts worse
|
19.6%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 22.2% |
20.6%
1.6 pts worse
|
16.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.7% |
15.2%
2.5 pts worse
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
14.6%
6.4 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.8%
0.5 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.5%
0.7 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.6% |
22.4%
5.8 pts better
|
19.8%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
3.7%
2.4 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.1% |
76.4%
1.3 pts worse
|
81.7%
6.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.0% |
75.6%
5.4 pts better
|
79.7%
1.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-01 · Fire 2022-12-01
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-08-18 · Fire 2021-08-18
24 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-11
F · Potential for more than minimal harm
2024-03-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-03-19
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-03-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-11
E · Potential for more than minimal harm
2024-03-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-11
D · Potential for more than minimal harm
2024-03-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-11
F · Potential for more than minimal harm
2022-12-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-28
F · Potential for more than minimal harm
2022-12-01
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-12-01
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-12-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-01
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 2023-01-16
D · Potential for more than minimal harm
2022-12-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-16
F · Potential for more than minimal harm
2021-08-18
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-08-18
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-08-18
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-09-24
F · Potential for more than minimal harm
2021-08-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-10-08
F · Potential for more than minimal harm
2021-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-23
F · Potential for more than minimal harm
2021-08-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-10-08
F · Potential for more than minimal harm
2021-08-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-09-28
F · Potential for more than minimal harm
2021-08-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-09-24
F · Potential for more than minimal harm
2021-08-18
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2021-09-24
E · Potential for more than minimal harm
2021-08-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-11-23
D · Potential for more than minimal harm
2021-08-18
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2021-10-08
D · Potential for more than minimal harm
2021-08-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-10-08
D · Potential for more than minimal harm
2021-08-18
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2021-10-08
Inspection history
Recent health citations
J · Immediate jeopardy
2025-07-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-13
D · Potential for more than minimal harm
2025-07-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-08
D · Potential for more than minimal harm
2024-08-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-09
E · Potential for more than minimal harm
2024-03-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-19
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-19
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-19
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-04-28
D · Potential for more than minimal harm
2024-03-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-28
J · Immediate jeopardy
2023-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-17
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-09-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-03-16
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-04-16
E · Potential for more than minimal harm
2023-03-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-16
D · Potential for more than minimal harm
2023-03-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-04-16
E · Potential for more than minimal harm
2022-12-01
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-12-01
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-12-01
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-12-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-12-01
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
2022-12-01
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-01
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 2022-12-28
D · Potential for more than minimal harm
2022-12-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-28
D · Potential for more than minimal harm
2022-12-01
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 2022-12-28
D · Potential for more than minimal harm
2022-12-01
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-12-28
G · Actual harm
2021-08-18
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 2021-09-17
F · Potential for more than minimal harm
2021-08-18
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-09-17
F · Potential for more than minimal harm
2021-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-18
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-18
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-18
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-18
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-18
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-18
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 2021-09-17
C · Minimal harm
2021-08-18
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2021-09-17
B · Minimal harm
2021-08-18
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2021-09-17
Penalties and ownership
What sits behind the stars
$31,663
2023-09-27
Fine
Fine · fine $31,663
Fine
Ownership
Sptmnr Properties Trust
5% Or Greater Direct Ownership Interest · Organization
Abp Trust
5% Or Greater Indirect Ownership Interest · Organization
Abp Trust
Operational/Managerial Control · Organization
Benton, Evrett
Operational/Managerial Control · Individual
Bilotto, Christopher
Operational/Managerial Control · Individual
Bilotto, Christopher
Corporate Director · Individual
Bilotto, Christopher
Corporate Officer · Individual
Blackrock Inc
5% Or Greater Indirect Ownership Interest · Organization
Blackrock Inc
Operational/Managerial Control · Organization
Branson, Marissa
Operational/Managerial Control · Individual
Brown, Matthew
Operational/Managerial Control · Individual
Brown, Matthew
Corporate Officer · Individual
Charles Schwab Investment Management, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Charles Schwab Investment Management, Inc.
Operational/Managerial Control · Organization
Clark, Jennifer
Operational/Managerial Control · Individual
Clark, Jennifer
Corporate Officer · Individual
D.e. Shaw & Co., L.p.
5% Or Greater Indirect Ownership Interest · Organization
D.e. Shaw & Co., L.p.
Operational/Managerial Control · Organization
Diversified Healthcare Trust
5% Or Greater Indirect Ownership Interest · Organization
Diversified Healthcare Trust
Operational/Managerial Control · Organization
Esfahani, Reza
Operational/Managerial Control · Individual
Flat Footed LLC
5% Or Greater Indirect Ownership Interest · Organization
Flat Footed LLC
Operational/Managerial Control · Organization
H/2 Special Opportunities Iv L.p.
5% Or Greater Indirect Ownership Interest · Organization
H/2 Special Opportunities Iv L.p.
Operational/Managerial Control · Organization
Mcglothlin, Chad
Operational/Managerial Control · Individual
Portnoy, Adam
5% Or Greater Indirect Ownership Interest · Individual
Portnoy, Adam
Operational/Managerial Control · Individual
Portnoy, Adam
Corporate Director · Individual
Snh Proj Lincoln Trs LLC
5% Or Greater Indirect Ownership Interest · Organization
Snh Proj Lincoln Trs LLC
Operational/Managerial Control · Organization
Snh Trs Licensee Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Snh Trs Licensee Holdco LLC
Operational/Managerial Control · Organization
Snh Trs, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Snh Trs, Inc.
Operational/Managerial Control · Organization
Sptmnr Properties Trust
Operational/Managerial Control · Organization
Stellar Cedars Management LLC
Operational/Managerial Control · Organization
Stellar Senior Living B LLC
Operational/Managerial Control · Organization
Stellar V LLC
Operational/Managerial Control · Organization
Vanguard Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Vanguard Group Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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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
Cambridge Care Center
Lakewood, CO
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
#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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