Cycle 1
Health 2025-08-27 · Fire 2025-08-27
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lakewood, CO
Edgewater Health and Rehabilitation
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1655 Eaton St, Lakewood, CO
(303) 238-5363
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
67
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1981-12-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.78
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,591
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
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
0
Baseline 37.50% · Performance 63.51% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.23
Baseline 3.38 hours · Performance 4 hours · Measure score 3.23 · Achievement 3.23 · Improvement 2.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | 43.52% |
50.57%
7 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 36% · Lower 95% interval 30.92% |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 81.82% |
95.27%
13.5 pts worse
|
Numerator 18 · Denominator 22 |
| Falls with major injury | 4.55% |
0.77%
3.8 pts worse
|
Numerator 1 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 14.88% |
8.2%
6.7 pts better
|
Numerator 18 · Denominator 121 |
| Staff flu vaccination coverage | 95.36% |
42%
53.4 pts better
|
Numerator 144 · Denominator 151 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 98.3% |
93.5%
4.8 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 96.5% · Q3 100.0% · Q4 100.0% · 4Q avg 98.3% |
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.4%
2.1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.5% |
7.4%
0.9 pts better
|
11.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 5.4% · Q4 13.2% · 4Q avg 6.5% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
5.0%
1.8 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 11.1% · Q3 6.0% · Q4 2.1% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.0% |
11.2%
9.2 pts better
|
19.6%
17.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 6.2% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.5% |
20.6%
3.1 pts better
|
16.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 10.0% · Q3 15.2% · Q4 21.9% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.3% |
0.1%
1.2 pts worse
|
0.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 1.7% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.3% |
15.2%
0.9 pts better
|
16.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 5.3% · Q3 15.3% · Q4 18.3% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
14.6%
5.4 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 17.8% · Q3 20.8% · Q4 22.2% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.8%
0.3 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
1.5%
2.5 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.7% · Q3 1.7% · Q4 3.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
22.4%
0.8 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 22.4% · Q3 34.5% · Q4 19.3% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
3.7%
0.7 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.8% · Q3 2.9% · Q4 3.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.2% |
76.4%
12.8 pts better
|
81.7%
7.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.7% · Q2 85.7% · Q3 93.8% · Q4 98.0% · 4Q avg 89.2% |
| 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 · Q1 3.2% · Q2 3.6% · Q3 3.6% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.5% |
75.6%
13.9 pts better
|
79.7%
9.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-14 · Fire 2024-02-14
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-08-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-08-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-08-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-22
F · Potential for more than minimal harm
2024-02-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-26
F · Potential for more than minimal harm
2024-02-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-02-14
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 2024-03-26
E · Potential for more than minimal harm
2024-02-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-26
F · Potential for more than minimal harm
2022-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-01
F · Potential for more than minimal harm
2022-11-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-31
E · Potential for more than minimal harm
2022-11-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-03
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 2022-12-22
E · Potential for more than minimal harm
2022-11-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-27
E · Potential for more than minimal harm
2022-11-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-11-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-27
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 2025-10-10
E · Potential for more than minimal harm
2025-08-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
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 2025-10-10
D · Potential for more than minimal harm
2025-08-27
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 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-10
G · Actual harm
2024-02-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-15
F · Potential for more than minimal harm
2024-02-14
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 2024-03-15
E · Potential for more than minimal harm
2024-02-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-14
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 2024-03-15
D · Potential for more than minimal harm
2022-11-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-23
D · Potential for more than minimal harm
2022-11-03
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 2022-11-23
Penalties and ownership
What sits behind the stars
Ownership
Bedinger, Mark
5% Or Greater Direct Ownership Interest · Individual
Bedinger, Mark
Operational/Managerial Control · Individual
Colavria Hospitality, Inc
Operational/Managerial Control · Organization
Duerst, Hannah
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#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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