Inspection Reports for
Cedars Healthcare Center Rehab, Skilled Nursing & Short Term Care
1599 Ingalls St, Lakewood, CO 80214, CO, 80214
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Enforcement
Deficiencies: 2
Date: Jul 16, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate treatment and care according to orders, resident preferences, and goals, specifically related to seizure management and medication administration.
Findings
The facility failed to ensure timely assessment and intervention during a resident's prolonged seizure episode, failed to provide seizure-specific staff training, and did not obtain or administer breakthrough seizure medication in a timely manner. Additionally, the facility failed to maintain accurate medication administration records for multiple residents.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals, resulting in immediate jeopardy to resident health or safety related to seizure management.
Failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, including accurate documentation of medication administration.
Report Facts
Residents reviewed for quality of care: 7
Residents affected by immediate jeopardy deficiency: 1
Days delay in obtaining midazolam medication: 6
Pages in report: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in seizure management failure and medication administration delay. |
| LPN #4 | Licensed Practical Nurse | Named in seizure management failure and communication with NP. |
| RN #3 | Registered Nurse | Named in communication with NP and care conference. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding seizure incident, staff training, and medication administration. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Provided plan to remove immediate jeopardy. |
| Nurse Practitioner | Nurse Practitioner (NP) | Involved in communication and physician orders during seizure event. |
| Medical Director | Medical Director (MD) | Interviewed regarding notification and assessment issues. |
| Staff Development Coordinator | Staff Development Coordinator (SDC) | Responsible for staff education on seizure management. |
| LPN #1 | Licensed Practical Nurse | Interviewed about seizure protocol knowledge. |
| RN #1 | Registered Nurse | Interviewed about seizure management practices. |
| LPN #3 | Licensed Practical Nurse | Interviewed about seizure monitoring and response. |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Interviewed about seizure monitoring training. |
| Certified Nurse Aide #2 | Certified Nurse Aide (CNA) | Interviewed about seizure monitoring responsibilities. |
| LPN #2 | Licensed Practical Nurse | Interviewed about medication administration documentation. |
Inspection Report
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of care related to treatment and care for optimal skin condition of a resident with hand contractures.
Findings
The facility failed to provide adequate skin care to prevent skin breakdown in Resident #1's contracted hands and between the resident's fingers and thumb, resulting in pressure wounds and skin issues. The facility lacked policies on contracture and skin integrity management and faced challenges with resident and family cooperation regarding splint use and wound care.
Deficiencies (1)
Failure to provide adequate skin care to prevent skin breakdown in Resident #1's contracted hands and between fingers and thumb.
Report Facts
Residents affected: 3
Residents affected: 1
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding Resident #1's care and wound management | |
| Director of Nursing (DON) | Interviewed regarding facility policies and family cooperation on Resident #1's care |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including restraint use, PASRR screening, activities of daily living assistance, catheter care, trauma-informed care, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure proper use and documentation of physical restraints, failure to conduct timely PASRR screening, inadequate assistance with scheduled showers, improper catheter care, lack of trauma-informed care planning for a resident with PTSD, and deficiencies in housekeeping and infection control practices.
Deficiencies (6)
Failed to ensure residents were free from physical restraints without proper evaluation, consent, physician orders, and quarterly risk evaluations for two residents.
Failed to conduct a preadmission screening resident review (PASRR) for a resident remaining beyond 30 days of provisional admission.
Failed to ensure a resident dependent on staff for bathing received scheduled showers as planned.
Failed to provide appropriate care and services for a resident with an indwelling catheter, including lack of physician orders, clinical indication, care plan, and proper catheter drainage bag positioning.
Failed to provide culturally competent, trauma-informed care for a resident with PTSD, including lack of assessment, care plan, and identification of triggers.
Failed to maintain an infection control program ensuring proper cleaning techniques, staff training, and adherence to disinfectant dwell times on two of three units.
Report Facts
Residents in sample: 34
Residents affected by restraint deficiency: 2
Residents affected by PASRR deficiency: 1
Residents affected by ADL assistance deficiency: 1
Residents affected by catheter care deficiency: 1
Residents affected by trauma-informed care deficiency: 1
Residents affected by infection control deficiency: 2
Showers received: 6
Showers refused: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Interviewed regarding restraint use for Resident #180 |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding restraint evaluation for Resident #180 |
| Director of Nursing | Director of Nursing | Interviewed regarding restraint use, PASRR screening, shower scheduling, catheter care, trauma-informed care, and infection control |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding shower scheduling and catheter care |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding shower scheduling, catheter care, and trauma-informed care |
| Social Service Assistant | Social Service Assistant | Interviewed regarding PASRR screening and trauma-informed care |
| Infection Preventionist | Infection Preventionist | Interviewed regarding catheter care and infection control |
| Housekeeper #1 | Housekeeper | Interviewed regarding cleaning procedures and training |
| Housekeeper #2 | Housekeeper | Interviewed regarding cleaning procedures and training |
| Housekeeping Director | Housekeeping Director | Interviewed regarding housekeeping deficiencies and training needs |
Inspection Report
Routine
Census: 34
Deficiencies: 7
Date: Mar 19, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, infection control, and facility policies.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints without proper evaluation or consent, failure to conduct timely PASRR screening, inadequate assistance with activities of daily living, improper catheter care, failure to provide trauma-informed care, medication labeling and storage issues, and deficiencies in infection prevention and control practices.
Deficiencies (7)
Failed to ensure residents were free from physical restraints without proper evaluation, consent, and physician orders for two residents.
Failed to conduct a preadmission screening resident review (PASRR) for a resident remaining beyond provisional admission approval.
Failed to ensure dependent resident received scheduled showers as required.
Failed to provide appropriate care and services for a resident with an indwelling catheter, including lack of physician orders, clinical indication, care plan, and proper catheter drainage bag handling.
Failed to provide trauma-informed and culturally competent care for a resident with PTSD, including lack of assessment, care plan, and identification of triggers.
Failed to ensure medications and biologicals were properly labeled with open dates and expired or discontinued medications were removed from medication carts and storage rooms.
Failed to maintain an effective infection prevention and control program, including improper cleaning techniques, lack of training and supervision of housekeeping staff, failure to disinfect high-touch surfaces, and non-adherence to disinfectant dwell times.
Report Facts
Residents reviewed: 34
Resident census: 34
Showers received: 6
Showers refused: 4
Insulin open date: 28
Expired IV antibiotics: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Interviewed regarding restraint use for Resident #180 |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding restraint evaluation for Resident #180 |
| Director of Nursing | Director of Nursing | Interviewed regarding restraint policies, PASRR screening, catheter care, trauma-informed care, medication management, and infection control |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding shower schedules and catheter care |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding shower schedules, catheter care, and trauma-informed care |
| Social Service Assistant | Social Service Assistant | Interviewed regarding PASRR screening and trauma-informed care |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication labeling and storage |
| Housekeeper #1 | Housekeeping Staff | Interviewed regarding cleaning procedures and training |
| Housekeeper #2 | Housekeeping Staff | Interviewed regarding cleaning procedures and training |
| Housekeeping Director | Housekeeping Director | Interviewed regarding housekeeping deficiencies and training needs |
| Infection Preventionist | Infection Preventionist | Interviewed regarding catheter care and infection prevention |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 17, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide necessary care and assistance with activities of daily living and mobility for Resident #4, and failure to provide appropriate treatment and care for Resident #1's non-pressure related skin condition resulting in osteomyelitis, hospitalization, and amputation.
Complaint Details
The complaint investigation revealed substantiated findings that the facility failed to assist Resident #4 with mobility and going outside as requested, and failed to identify and respond to Resident #1's worsening non-pressure related skin condition, resulting in serious harm including hospitalization and amputation.
Findings
The facility failed to ensure Resident #4 received assistance with mobility and going outside as per care plan, and failed to identify and respond appropriately to Resident #1's non-pressure related skin condition, leading to serious harm including amputation. Immediate jeopardy was identified but removed after the facility implemented corrective actions including staff education and systemic changes.
Deficiencies (2)
Failure to provide necessary care and assistance with mobility consistent with Resident #4's needs and choices.
Failure to provide appropriate treatment and care according to orders, resulting in osteomyelitis and amputation of Resident #1's left great toe.
Report Facts
Residents affected: 3
Hospitalization duration: 8
Braden scale score: 14
Education completion date: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Completed skin assessment on Resident #1 on 10/3/23 and documented no wounds; interviewed regarding wound care failures. |
| LPN #3 | Licensed Practical Nurse | Interviewed about wound assessments and reporting; last saw Resident #1's scab four days before 10/6/23. |
| LPN #1 | Licensed Practical Nurse, Wound Care Nurse | Conducted wound care rounds and was not notified about Resident #1's scab. |
| Certified Nurse Aide #1 | CNA | Interviewed about assisting residents outside and observations related to Resident #4 and Resident #1. |
| Director of Nursing | DON | Interviewed about facility policies, wound care failures, and immediate jeopardy removal plan. |
| Activities Director | AD | Interviewed about activities assistance and Resident #4's participation. |
| Medical Director | MD | Interviewed about wound care and Resident #1's risk factors and wound development. |
Inspection Report
Routine
Census: 81
Deficiencies: 2
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with policies and procedures related to pneumococcal immunizations for residents.
Findings
The facility failed to implement proper policies and procedures for pneumococcal vaccinations, including failure to administer the vaccine after consent for some residents and failure to offer the vaccine yearly after refusal for others. Several residents had consents signed but did not receive the vaccine.
Deficiencies (2)
Failed to administer pneumococcal vaccine after consent for Resident #2 and #5
Failed to offer pneumococcal vaccination yearly after refusal for Resident #1, #3, and #8
Report Facts
Resident census: 81
Residents coded as receiving pneumococcal vaccination: 31
Residents reviewed for immunizations: 8
Residents with failed pneumococcal immunization procedures: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed regarding immunization policies and procedures | |
| Infection Preventionist (IP) | Interviewed regarding immunization records and facility procedures |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 16, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to honor residents' rights to self-determination and choice, failure to maintain a safe and comfortable environment, and failure to provide appropriate assistance with activities of daily living including incontinence care.
Complaint Details
The complaint investigation focused on Resident #1's right to shower according to preference, temperature issues causing discomfort and rashes, and pervasive urine odors due to inadequate incontinence care for Residents #6, #5, and #2. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure consistent showers according to resident preferences, maintain safe temperature ranges in resident areas, and provide adequate incontinence care resulting in odors and discomfort. Several residents were affected by these deficiencies, with documentation and care practices not meeting facility policies.
Deficiencies (3)
Failed to provide consistent showers for Resident #1 according to his preferences and routine shower schedule.
Failed to ensure temperatures in hallways, dining room, and resident rooms were within the safe range of 71°F to 81°F.
Failed to provide and document regular incontinence care to prevent odors throughout the facility affecting multiple residents.
Report Facts
Showers received vs scheduled: 5
Showers received vs scheduled: 4
Showers received vs scheduled: 2
Temperature: 85
Temperature: 78
Toileting assistance frequency: 1.3
Toileting assistance frequency: 1.2
Toileting assistance frequency: 0.63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide #2 | CNA | Interviewed regarding shower scheduling and refusals for Resident #1. |
| Certified Nursing Aide #3 | CNA | Interviewed about shower refusals and scheduling for residents. |
| Director of Nursing | DON | Interviewed about shower frequency recommendations, documentation, and incontinence care. |
| Maintenance Director | MTD | Interviewed about temperature monitoring and facility heating system. |
| Nursing Home Administrator | NHA | Interviewed about facility policies, grievance handling, and temperature concerns. |
| Maintenance Worker #1 | MW | Interviewed about temperature complaints and mitigation efforts. |
| Certified Nurse Aide #1 | CNA | Interviewed about incontinence care for Resident #6. |
| Housekeeper #1 | HSKP | Interviewed about odor control efforts in the facility. |
Inspection Report
Routine
Deficiencies: 9
Date: Dec 1, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, activities, medication administration, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning, maintaining a safe and homelike environment during renovations, preventing resident-to-resident abuse, providing adequate assistance with activities of daily living, ensuring appropriate activities programming and qualified activities director, medication administration errors, infection control deficiencies, and ensuring safe storage and administration of medications.
Deficiencies (9)
Failure to allow resident to participate in the development and implementation of her person-centered plan of care.
Failure to provide a comfortable and homelike environment during facility renovation, including cleanliness and unpacking residents' belongings.
Failure to prevent resident-to-resident physical abuse between Residents #18 and #32 and between Residents #40 and #74.
Failure to provide care and assistance to perform activities of daily living, including repositioning and showering for residents.
Failure to provide activities to meet all residents' needs, including lack of one-to-one activities and failure to employ a qualified activities director.
Failure to ensure resident environment was free from accident hazards, specifically medications left at bedside without authorization.
Failure to provide appropriate treatment and services to a resident with dementia, including effective person-centered interventions to manage wandering.
Failure to ensure a resident was free from significant medication errors, specifically failure to administer morning medications before hospital transport.
Failure to provide and implement an infection prevention and control program, including inadequate cleaning practices and improper storage of oxygen tubing.
Report Facts
Sample residents: 42
One-to-one activity visits: 2
One-to-one activity visits: 4
One-to-one activity visits: 5
Showers received: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed practical nurse #2 | LPN | Interviewed regarding failure to assess and monitor resident after physical abuse incident |
| Certified nursing assistant #1 | CNA | Witnessed resident-to-resident physical abuse between Residents #40 and #74 |
| Activity director | AD | Interviewed regarding lack of certification and failure to provide adequate one-to-one activities |
| Housekeeping supervisor | HSS | Interviewed regarding cleaning procedures and deficiencies |
| Housekeeper #1 | HS | Observed performing inadequate cleaning and disinfection |
| Director of nursing | DON | Interviewed regarding multiple deficiencies including abuse investigation, activities program, medication administration, and infection control |
| Nursing home administrator | NHA | Interviewed regarding facility policies, abuse investigations, and activities program oversight |
| Agency registered nurse #1 | ARN | Observed administering medications late and interviewed regarding medication error |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 14
Date: Aug 11, 2021
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident rights violations, dignity, respect, care planning participation, staff responsiveness, and infection control practices.
Complaint Details
The complaint investigation was triggered by multiple resident grievances and concerns including racial discrimination, inadequate care, failure to respond to grievances, and infection control issues. The facility was found to have substantiated deficiencies in these areas.
Findings
The facility was found deficient in multiple areas including failure to prevent resident-to-resident verbal abuse and discrimination, failure to ensure resident participation in care planning, inadequate response to grievances, failure to maintain a safe and sanitary environment, insufficient assistance with activities of daily living, failure to provide timely ancillary services, medication administration errors, inadequate respiratory care, insufficient staffing, improper infection control practices, and failure to properly label and store medications.
Deficiencies (14)
Failure to prevent resident-to-resident verbal abuse and discrimination including racial slurs.
Failure to ensure residents participated in care planning and care conferences.
Failure to provide a safe, sanitary, and comfortable environment for residents.
Failure to provide prompt efforts to resolve resident grievances.
Failure to timely report and investigate alleged abuse.
Failure to provide assistance with activities of daily living including bathing according to resident preferences.
Failure to provide personalized activity programs and engagement for residents.
Failure to follow physician orders for medication administration and glucometer audits.
Failure to provide appropriate respiratory care including oxygen tubing changes and adherence to oxygen orders.
Failure to provide restorative therapy and range of motion exercises as ordered.
Failure to ensure fall prevention measures including placement of fall mats.
Failure to provide enteral feedings according to physician orders.
Failure to label and store medications properly including expired medications and opened dates.
Failure to implement effective infection prevention and control program including proper PPE use, hand hygiene, COVID-19 testing, and housekeeping training.
Report Facts
Resident census: 66
Residents needing assistance with bathing: 54
Residents dependent on bathing: 12
Residents needing assistance with toileting: 58
Residents dependent on toileting: 3
Residents needing assistance with dressing: 60
Residents dependent on dressing: 4
Residents needing assistance with transfers: 35
Residents dependent on transfers: 13
Residents needing assistance with eating: 29
Residents dependent on eating: 4
Medication administration frequency: 6
Oxygen tubing change frequency: 7
Medication expiration days: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Observed wearing cloth mask below nose in droplet precaution room and not changing mask immediately |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including infection control, staffing, medication labeling |
| RCNA #2 | Restorative Certified Nurse Assistant | Interviewed regarding restorative therapy services and resident care |
| SW | Social Worker | Interviewed regarding ancillary services and grievance follow-up |
| LED | Life Enrichment Director | Interviewed regarding activity programming and resident engagement |
| MDSC | Minimum Data Set Coordinator | Observed serving meals without offering hand hygiene assistance |
| HSK #1 | Housekeeper | Observed improper cleaning practices and lack of chemical training |
| HSK #2 | Housekeeper | Observed improper cleaning practices and lack of chemical training |
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