Cedars Healthcare Center

In the surveyor’s words

From the most serious findings on record at Cedars Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 16, 2025

  Based on record review, observations and interviews, the facility failed to ensure one (#7) of six residents reviewed for quality of care out of seven sample residents, received treatment and care in accordance with professional standards of practice.IMMEDIATE JEOPARDYResident #7 was admitted on [DATE] with diagnoses of Parkinson's disease (a progressive disease that causes symptoms such as tremors, stiffness and slow movement), epilepsy without status epilepticus (seizure lasting longer than five minutes, or two or more seizures without the resident gaining consciousness in between them), chronic respiratory failure, dependence on supplemental oxygen and cognitive communication deficit.On 6/26/25, Resident #7 experienced seizure activity that lasted longer than 30 minutes. […]

• Immediate jeopardy, isolatedF684Oct 17, 2023

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of eight sample residents received treatment and care in accordance with professional standards of practice. The facility failed to identify and respond to Resident #1's non-pressure related skin condition resulting in the development of osteomyelitis (bone infection), hospitalization and amputation of his left great toe. Resident #1, diagnosed with heart disease with heart failure and type 2 diabetes mellitus, was admitted to the facility 12/14/21. […]

• Actual harm, isolatedF550Aug 18, 2021

  Based on observations, interviews, and record review, the facility failed to ensure respect and dignity during resident to resident interactions in three (#50, #36, and #2) of three out of 32 sample residents. The facility failed to ensure Resident #50 had a dignified living experience. The facility failed to address complaints made by Resident #50 regarding negative comments and name calling being said to her by Resident #20 since October 2020. Resident #20 made comments regarding Resident #50's weight, which weretwo-ton, fat, and lazy. […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2026

  Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and dishroom. Specifically, the facility failed to ensure:-Staff used proper hand hygiene during meal service;-Food was held at the correct temperature;-Kitchen was maintained, in good repair to be able to have a cleanable surface.Findings include: I. Failed to ensure dietary staff performed appropriate hand hygiene during meal serviceA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 6/17/26. […]

• No harm, potential for more than minimal, widespreadF725Aug 18, 2021

  Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of inadequate staffing, the facility had delayed call light response, failed to provide assistance with activities of daily living (ADLs ). Cross-reference F676 failure to provide assistance with activities of daily living and F688 for restorative services. Findings include: I. […]