Cedars Healthcare Center
1599 Ingalls St, Lakewood, CO 80214 · Jefferson County · 130 certified beds · avg 108 residents/day · certified since Dec 27, 1984
Part of chain: STELLAR SENIOR LIVING (7 facilities, chain avg rating 2.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jul 16, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 13, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 17, 2023 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 9, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 18, 2021 · F-0550
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Why it matters: Being treated without dignity harms a resident's self-worth, mental health, and overall quality of life.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 17, 2021 (Deficient, Provider has date of correction)
All citations in the current public record (43)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 11, 2026 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Jun 11, 2026 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jul 16, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 16, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 20, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 19, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · from a complaint |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · from a complaint |
| Mar 19, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Oct 17, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 17, 2023 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Dec 1, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Dec 1, 2022 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Dec 1, 2022 | E · Potential for harm, repeated | The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. |
| Dec 1, 2022 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Dec 1, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 1, 2022 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Dec 1, 2022 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Dec 1, 2022 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 1, 2022 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 1, 2022 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Aug 18, 2021 | ▲ G · Actual harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 18, 2021 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Aug 18, 2021 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 18, 2021 | E · Potential for harm, repeated | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Aug 18, 2021 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Aug 18, 2021 | E · Potential for harm, repeated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Aug 18, 2021 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 18, 2021 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Aug 18, 2021 | E · Potential for harm, repeated | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Aug 18, 2021 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 18, 2021 | E · Potential for harm, repeated | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. |
| Aug 18, 2021 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 18, 2021 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Aug 18, 2021 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Aug 18, 2021 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Aug 18, 2021 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 18, 2021 | C · Minimal risk, facility-wide | The facility did not give residents important notices in a format and language they can understand — for example, translated documents or accessible formats for those with vision or hearing loss. |
| Aug 18, 2021 | B · Minimal risk, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (10 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 18 | 1 | G ▲ |
| 2022 | 10 | 0 | E |
| 2023 | 3 | 1 | J ▲ |
| 2024 | 8 | 0 | E |
| 2025 | 2 | 1 | J ▲ |
| 2026 | 2 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $55,908.
| Date | Type | Amount / length |
|---|---|---|
| Jul 16, 2025 | Fine | $24,245 |
| Sep 27, 2023 | Fine | $31,663 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.64 | 3.89 | 3.95 | bottom 46% in Colorado; bottom 44% in the U.S. |
| Registered Nurse hours | 0.59 | 0.86 | 0.69 | bottom 22% in Colorado; top 50% in the U.S. |
| Weekend total nurse staffing | 3.60 | 3.44 | 3.50 | top 34% in Colorado; top 38% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.48 | 0.61 | 0.48 | bottom 39% in Colorado; top 35% in the U.S. |
| Total nursing staff turnover (%) | 26.7 | 47.1 | 45.8 | top 5% in Colorado; top 9% in the U.S. |
| RN turnover (%) | 9.1 | 44.6 | 42.9 | top 3% in Colorado; top 3% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.18, RN 0.51, weekend 3.14. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Charles Schwab Investment Management, INC. | Organization | 5% or Greater Indirect Ownership Interest | — | 03/22/2024 |
| D.e. Shaw & Co., L.P. | Organization | 5% or Greater Indirect Ownership Interest | — | 03/22/2024 |
| Diversified Healthcare Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2020 |
| H/2 Special Opportunities IV L.P. | Organization | 5% or Greater Indirect Ownership Interest | — | 03/22/2024 |
| SNH Proj Lincoln TRS LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2024 |
| SNH TRS Licensee Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2020 |
| SNH TRS, INC. | Organization | 5% or Greater Indirect Ownership Interest | — | 01/01/2020 |
| Sptmnr Properties Trust | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/2024 |
| Abp Trust | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/22/2024 |
| Benton, Evrett | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2021 |
| Benton, Evrett | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2021 |
| Bilotto, Christopher | Individual | Corporate Director | NOT APPLICABLE | 01/01/2024 |
| Bilotto, Christopher | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Bilotto, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Bilotto, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Blackrock INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/22/2024 |
| Branson, Marissa | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2021 |
| Branson, Marissa | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2021 |
| Brown, Matthew | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2023 |
| Brown, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Edgewater Health and Rehabilitation | 0.1 mi | Lakewood, CO | ★★★★★ | 4/5 | |
| Cambridge Care Center | 0.1 mi | Lakewood, CO | ★★★☆☆ | 2/5 | abuse |
| Sierra Post Acute | 0.2 mi | Lakewood, CO | ★★☆☆☆ | 1/5 | abuse |
| Harmony Pointe Care Center | 1.1 mi | Lakewood, CO | ★★★☆☆ | 2/5 | |
| Wheatridge Care Center | 1.2 mi | Wheat Ridge, CO | ★★★☆☆ | 2/5 | |
| Western Hills Health Care Center | 1.6 mi | Lakewood, CO | ★★★☆☆ | 3/5 | |
| Allison Care Center | 1.6 mi | Lakewood, CO | ★★☆☆☆ | 2/5 | abuse |
| Sloan's Lake Rehabilitation Center | 1.6 mi | Denver, CO | ★★★★★ | 5/5 | |
| Mapleton Post Acute | 1.6 mi | Lakewood, CO | ★★★★☆ | 3/5 | |
| Oakwood Care and Rehabilitation | 1.7 mi | Lakewood, CO | ★☆☆☆☆ | 1/5 | abuse |
| Rehabilitation Center at Sandalwood, the | 1.9 mi | Wheat Ridge, CO | ★★★★☆ | 3/5 | |
| Lakeside Post Acute | 1.9 mi | Wheat Ridge, CO | ★★★☆☆ | 2/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 065202.