Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edgewater Health And Rehabilitation during CMS and state inspections, most recent first.
Kitchen staff failed to properly clean food thermometers before and after use, instead using an incorrect method involving alcohol wipes and their packaging, which did not meet professional standards or facility policy. Both the cook and dietary manager demonstrated and confirmed this improper cleaning technique during interviews.
The facility failed to maintain infection control practices during housekeeping and resident care. A housekeeper repeatedly changed gloves without performing hand hygiene while cleaning a resident room, a CNA provided incontinence care for a resident with a wound and then continued hands-on care without changing gloves or cleaning hands, and multiple staff members provided high-contact care to residents on EBP without wearing gowns. An RN also administered tube feeding to a resident with a feeding tube without a gown.
Failure to Notify Representative of Personal Funds Balance: A Medicaid-funded resident’s personal funds account exceeded the $2,000 resource limit, and the facility did not notify the resident or legal representative when the balance reached $200 below the eligibility threshold. The financial coordinator said notifications were made at $2,000 and was unaware of the earlier notice requirement, while the NHA said the resident’s representative had been contacted to spend down the account but no documentation was available to confirm that communication.
A resident with cerebral palsy and depression was observed using a wheelchair seatbelt and foot straps, and the MDS showed daily trunk and limb restraints. The record lacked a physician order identifying the medical symptom for the restraints, lacked ongoing restraint evaluations after the initial assessments, and did not document less restrictive measures tried before the seatbelt and foot straps were used. Staff said the resident could not release the straps herself, and the DON said assessments were supposed to occur quarterly.
Failure to Provide Required Meal Assistance: A resident with Alzheimer's disease, DM2, CKD, COPD, HTN, and hypothyroidism had a care plan for a pureed diet, fortified foods, and 1:1 meal assistance with verbal cues. During two meal observations, CNAs assisted other residents but did not physically assist this resident, who was only encouraged to eat and left the dining room with most of the meal untouched. Staff interviews confirmed the resident had cognitive impairment and needed 1:1 help during meals.
A resident with dementia, COPD, and respiratory failure with hypoxia was ordered continuous oxygen at 2 LPM via nasal cannula, but observations showed the concentrator repeatedly set at 4.5 LPM and at other times no oxygen was being worn, including during meals and while asleep. An LPN confirmed the resident was off oxygen and applied it at 2 LPM after checking an O2 saturation of 91% on room air; the DON stated oxygen should be checked three times daily and documented in the TAR.
Improper Cleaning of Food Thermometers in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff properly cleaned food thermometers before and after use, resulting in a deficiency related to food safety and sanitation. During observation of a lunch meal service, the cook was seen cleaning the thermometer by poking it through the middle of an alcohol wipe and its packaging, then running the wipe and packaging up and down the probe. This method was repeated multiple times for different food items, including beans, pureed quesadillas, and sour cream. The alcohol wipe was not fully opened, and the packaging was in contact with the thermometer probe during cleaning, which does not meet professional standards or the facility's own policy for cleaning food-contact equipment. Interviews with the cook and the dietary manager revealed that both staff members had been taught to clean thermometers in this improper manner, using the alcohol wipe and its packaging rather than opening the wipe and cleaning the probe without the packaging touching it. The dietary manager demonstrated the same incorrect technique during the interview. The facility's policy and state regulations require that food-contact surfaces and utensils, including thermometers, be cleaned to sight and touch, and that thermometers be cleaned, rinsed, sanitized, and air-dried before and after use. These requirements were not followed, as observed and confirmed through staff interviews.
Infection Control Failures During Housekeeping, Incontinence Care, and EBP Care
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. During housekeeping observations, Housekeeper #1 cleaned a resident room while repeatedly removing and replacing gloves without performing hand hygiene between glove changes. She handled chemicals, cleaning tools, the television remote, bedside table, mirror, toilet, floor areas, and mop heads, but did not clean her hands after each glove removal, including after cleaning the toilet and before moving to other areas of the room. The facility also failed to ensure appropriate hand hygiene during incontinence care for Resident #23. During the observation, CNA #1 removed the resident’s soiled brief, performed perineal care, and applied a clean brief. Without changing gloves or performing hand hygiene, the CNA then dressed the resident, assisted her to sit up, put on shoes, applied a gait belt, transferred her to a wheelchair, placed her oxygen cannula and tubing, removed trash, and continued wheeling the resident out of the room before stopping to discard trash and perform hand hygiene. Resident #23 was also noted to have a wound on her left shin and was on enhanced barrier precautions. The facility further failed to ensure staff wore appropriate PPE during high-contact care for residents on enhanced barrier precautions. Resident #23 had a large bandage on her left shin, and staff performed transfers, dressing, and other hands-on care without gowns. CNA #1 transferred the resident into bed without a gown, and later CNA #2 and CNA #3 provided high-contact care including positioning, applying socks, placing a gait belt, transferring the resident to a wheelchair, and dressing her without the required gown use. RN #1 also provided tube feeding to Resident #4, who had a feeding tube and was on enhanced barrier precautions, while wearing gloves but no gown.
Failure to Notify Representative of Personal Funds Balance
Penalty
Summary
The facility failed to manage a Medicaid-funded resident’s personal funds account accurately by not notifying the resident or the resident’s legal representative when the account reached $200.00 less than the eligibility resource limit. Record review showed the resident’s trust account balance was $2,631.92, which was $631.92 over the $2,000.00 limit for Medicaid-funded residents. During interviews, the financial coordinator stated that residents or their representatives were notified when accounts reached $2,000.00 and said she was unaware that notification was required when the account reached $200.00 less than the resource limit. The nursing home administrator stated the facility had been in contact with the resident’s representative to spend down the account once it reached the allotted limit, but the facility was unable to provide documentation showing that communication had occurred regarding the account balance.
Physical restraints used without complete order and ongoing evaluation
Penalty
Summary
The facility failed to ensure Resident #10 was free from physical restraints unless needed for medical treatment. Resident #10, who was under 65 years old, had diagnoses of cerebral palsy and depression and was cognitively intact with a BIMS score of 15 out of 15. The resident was observed seated in a wheelchair with a seatbelt and foot straps in place on multiple occasions, and the MDS indicated trunk and limb restraints were used daily. Record review showed a physical restraint evaluation and consent were completed in October 2024 for the foot straps and in November 2024 for the wheelchair seatbelt. The October evaluation documented a trial without foot straps was not successful because both feet could not be positioned independently and staff had to place the feet back on the foot pedals. The November evaluation documented a trial without the seatbelt was not successful and stated the resident benefited from the seatbelt for midline, upright positioning in the custom power wheelchair. However, the EMR did not show ongoing evaluations after November 2024 to confirm the continued appropriateness of the seatbelt and foot straps, including a trial without the restraints. The physician order for the wheelchair seatbelt and foot straps directed staff to apply them when the resident was seated in the wheelchair and to release them every shift, as needed, and at the resident's request, but it did not identify the medical symptom for their use. The EMR also did not show documentation that less restrictive interventions were attempted before use of the seatbelt and foot straps. Staff interviews indicated the resident liked to stretch backward, could not undo the straps herself, and staff only released the straps when she was getting out of the chair, while the DON stated assessments were supposed to be completed every quarter and that the resident knew the devices were restraints because she could not release them herself.
Failure to Provide Required Meal Assistance
Penalty
Summary
The facility failed to ensure Resident #69 received the necessary assistance with meals to maintain good nutrition and personal care. Resident #69 had diagnoses including Alzheimer's disease, type 2 diabetes mellitus, chronic kidney disease, COPD, hypertension, and hypothyroidism. The 8/13/25 MDS showed memory problems, moderately impaired cognitive skills for daily decision making, and a need for maximum assistance from one staff member with meals, transfers, and personal hygiene. The nutrition care plan, revised 7/4/25, directed staff to provide a pureed diet with thin liquids, fortified foods, one-on-one assistance during meals, verbal cues to encourage swallowing after bites or sips to prevent pocketed food, and to offer one food item at a time. During observations on 8/24/25 and 8/25/25, Resident #69 was seated at the dining table with her meal placed within reach, but staff did not provide physical feeding assistance. On both occasions, CNAs assisted other residents at the table while Resident #69 was only encouraged to eat; her plate remained full when she left the dining room, and she consumed only part of her milk. Staff interviews indicated the resident was usually set up for meals and sometimes received cueing or occasional physical help, while the RN and MD acknowledged she had cognitive impairment and needed one-on-one meal assistance. The MD stated the resident needed one-on-one assistance during meals.
Improper Oxygen Flow and Missed Continuous Oxygen for a Resident
Penalty
Summary
The facility failed to ensure Resident #56 received respiratory care in accordance with the physician’s order, the care plan, and the resident’s choice. Resident #56 had diagnoses including dementia with other behavioral disturbances, respiratory failure with hypoxia, chronic obstructive pulmonary disease, and cognitive communication deficit. The resident’s MDS indicated severe cognitive impairment with a BIMS score of 4 out of 15, maximum assistance with ADLs, and a need for continuous oxygen at 2 LPM via nasal cannula. The respiratory care plan, dated 4/19/24, documented the resident was at risk for hypoxia and required supplemental oxygen at 2 LPM continuously. Observations showed the resident’s oxygen concentrator was repeatedly set at 4.5 LPM instead of the ordered 2 LPM on multiple occasions, and at other times the resident was not wearing supplemental oxygen at all, including while sitting in the dining room and while asleep in her room. During an interview, an LPN confirmed the resident was not wearing the nasal cannula, checked the oxygen saturation at 91% on room air, and then applied oxygen at 2 LPM. The LPN stated it was the nurse’s responsibility to ensure residents were on the appropriate oxygen liter flow rates and said he did not realize the resident was not wearing oxygen when administering morning medications. The DON stated oxygen should be checked three times per day and documented in the TAR with oxygen saturation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 513 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cambridge Care Center | 0 mi | ★★★★★ | 0 | 0 |
| Cedars Healthcare Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Sierra Post Acute | 0.3 mi | ★★★★★ | 10 | 0 |
| Harmony Pointe Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Wheatridge Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Edgewater Health And Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.