Cycle 1
Health 2025-01-30 · Fire 2025-01-30
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Littleton, CO
Cherrelyn Healthcare Center
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
5555 S Elati St, Littleton, CO
(303) 798-8686
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
190
Certified beds
Average residents
167
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
0.58
Registered nurse staffing
LPN hours / resident day
0.55
Licensed practical nurse staffing
Aide hours / resident day
1.86
Nurse aide staffing
Weekend hours
2.54
Weekend nurse staffing
RN turnover
22%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.4%
1.2 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 48.2% |
7.4%
40.8 pts worse
|
11.4%
36.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.0%
0.8 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.7% |
11.2%
0.5 pts worse
|
19.6%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 26.4% |
20.6%
5.8 pts worse
|
16.7%
9.7 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 | 15.1% |
15.2%
0.1 pts better
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
14.6%
0.2 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.8%
0.7 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.5% |
22.4%
12.9 pts better
|
19.8%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
3.7%
0.8 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
76.4%
20.3 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.5% |
75.6%
20.9 pts better
|
79.7%
16.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-16 · Fire 2023-08-16
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-06-15 · Fire 2022-06-15
21 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-08-30
F · Potential for more than minimal harm
2025-01-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-30
F · Potential for more than minimal harm
2025-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-30
F · Potential for more than minimal harm
2025-01-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-01-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-01-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-01
E · Potential for more than minimal harm
2025-01-30
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-04-01
F · Potential for more than minimal harm
2023-08-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-08-16
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-11-15
F · Potential for more than minimal harm
2023-08-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-15
F · Potential for more than minimal harm
2023-08-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-15
F · Potential for more than minimal harm
2023-08-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-15
F · Potential for more than minimal harm
2023-08-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-15
F · Potential for more than minimal harm
2023-08-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-29
F · Potential for more than minimal harm
2023-08-16
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-02-29
F · Potential for more than minimal harm
2023-08-16
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-15
F · Potential for more than minimal harm
2023-08-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-08-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-15
D · Potential for more than minimal harm
2022-06-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-15
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-07-25
D · Potential for more than minimal harm
2022-06-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-06-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-07-25
D · Potential for more than minimal harm
2022-06-15
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 2022-08-14
D · Potential for more than minimal harm
2022-06-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-06-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-06-15
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-06-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-06-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-06-15
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2022-07-25
D · Potential for more than minimal harm
2022-06-15
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-06-15
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-07-25
D · Potential for more than minimal harm
2022-06-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-25
D · Potential for more than minimal harm
2022-06-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-07-25
D · Potential for more than minimal harm
2022-06-15
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-06-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-11
E · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-30
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-30
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 2025-02-26
D · Potential for more than minimal harm
2025-01-30
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-02-26
F · Potential for more than minimal harm
2023-08-16
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 2023-09-27
E · Potential for more than minimal harm
2023-08-16
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 2023-10-04
E · Potential for more than minimal harm
2023-08-16
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 2023-09-27
E · Potential for more than minimal harm
2023-08-16
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 2023-09-11
E · Potential for more than minimal harm
2023-08-16
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-08-16
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-08-16
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 2023-09-27
D · Potential for more than minimal harm
2023-08-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-08-16
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-10-04
C · Minimal harm
2023-08-16
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-09-27
H · Actual harm
2022-06-15
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 2022-07-15
G · Actual harm
2022-06-15
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 2022-07-15
G · Actual harm
2022-06-15
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 2022-07-15
G · Actual harm
2022-06-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-15
G · Actual harm
2022-06-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-15
G · Actual harm
2022-06-15
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 2022-07-15
G · Actual harm
2022-06-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-06-15
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-06-15
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-06-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-06-15
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-15
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 2022-07-15
E · Potential for more than minimal harm
2022-06-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-15
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-15
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-15
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 2022-07-15
D · Potential for more than minimal harm
2022-06-15
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 2022-07-15
D · Potential for more than minimal harm
2022-06-15
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 2022-07-15
D · Potential for more than minimal harm
2022-06-15
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2022-07-15
Penalties and ownership
What sits behind the stars
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
Becton, Josh
Operational/Managerial Control · Individual
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
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
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
Marques, Abdel
Operational/Managerial Control · Individual
Martinez, Rachel
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 Cherrelyn 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
#1
Littleton Care And Rehabilitation Center
Littleton, CO
4-star overall rating with 4-star inspections with $7,781 in total fines with 3 recent health deficiencies
#2
Wellsprings Care Center
Englewood, CO
2-star overall rating with 1-star inspections with abuse icon flag with 19 recent health deficiencies
#3
Englewood Post Acute And Rehabilitation
Englewood, CO
4-star overall rating with 4-star inspections with $17,696 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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