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Nursing Home Inspect > Colorado > Arapahoe County Data as of September 2024

    Cherrelyn Healthcare Center

    For profit - Corporation  ·  5555 S Elati St, Littleton, CO 80120  ·  See home’s Medicare page

    Affiliated With Stellar Senior Living
    People or companies with an ownership interest in or managerial control of this home, according to CMS data.
    3.13
    Nurse hours/resident/day
    Reported total nurse staffing hours per resident per day.
    State Average: 3.7
    30.8%
    Nurse turnover
    The percentage of nursing staff who stopped working at the home over a 12-month period.
    State Average: 55.2%
    190
    Certified beds
    Qualifying beds in the certified provider or supplier facility.
    178
    Average residents/day
    Average number of residents based on daily census.
    Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
    Direct owners
    Snh Proj Lincoln Trs Llc (100%)
    Indirect owners
    Blackrock Inc
    Diversified Healthcare Trust
    Snh Trs Licensee Holdco Llc
    Snh Trs, Inc.
    State Street Corporation
    Vanguard Group Inc
    Managerial control
    Stellar Cherrelyn Management Llc since Aug, 2021
    Stellar V Llc since Aug, 2021
    Managing employee(s)
    Evrett Benton since Aug, 2021
    Robert Clouatre since Jan, 2020
    Linda Wheaton since Jan, 2020

    Inspection Reports

    68

    total deficiencies

    5

    infection-related deficiencies

    This home violated federal standards protecting residents from the spread of infections.

    Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
    Aug 16, 2023
    Standard report
    10 deficiencies
    C

     to F
    F
    Full report
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Rights Deficiency — F0550
    Failure to: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0761
    Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nutrition and Dietary Deficiency — F0805
    Failure to: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0583
    Failure to: Keep residents' personal and medical records private and confidential.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0690
    Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0695
    Failure to: Provide safe and appropriate respiratory care for a resident when needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0740
    Failure to: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0577
    Failure to: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Feb 13, 2023
    Complaint report
    1 deficiency
    E
    Full report
    Resident Rights Deficiency — F0584
    Failure to: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Jun 15, 2022
    Standard report
    21 deficiencies
    (2 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    $116,357 Fine
    D

     to H
    H
    Full report
    Nursing and Physician Services Deficiency — F0725
    Failure to: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Some people affected
    Seriousness
    H
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
    Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Quality of Life and Care Deficiency — F0697
    Failure to: Provide safe, appropriate pain management for a resident who requires such services.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Quality of Life and Care Deficiency — F0686
    Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Administration Deficiency — F0835
    Failure to: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0867
    Failure to: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Infection Control Deficiency — F0885
    Failure to: Report COVID19 data to residents and families.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Nursing and Physician Services Deficiency — F0726
    Failure to: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Quality of Life and Care Deficiency — F0744
    Failure to: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0943
    Failure to: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0695
    Failure to: Provide safe and appropriate respiratory care for a resident when needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0760
    Failure to: Ensure that residents are free from significant medication errors.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0578
    Failure to: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0585
    Failure to: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Administration Deficiency — F0849
    Failure to: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0690
    Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Mar 28, 2022
    Complaint report
    9 deficiencies
    $33,348 Fine
    D

     to G
    G
    Full report
    Resident Rights Deficiency — F0550
    Failure to: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Nursing and Physician Services Deficiency — F0725
    Failure to: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0835
    Failure to: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Rights Deficiency — F0585
    Failure to: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nutrition and Dietary Deficiency — F0802
    Failure to: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0697
    Failure to: Provide safe, appropriate pain management for a resident who requires such services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0825
    Failure to: Provide or get specialized rehabilitative services as required for a resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Jan 20, 2022
    Complaint report
    5 deficiencies
    $31,320 Fine
    D

     to G
    G
    Full report
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Resident Rights Deficiency — F0580
    Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0622
    Failure to: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0623
    Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0626
    Failure to: Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Oct 28, 2021
    Infection report
    1 deficiency
    (1 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    $9,750 Fine
    E
    Full report
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    May 6, 2021
    Standard report
    21 deficiencies
    (2 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    D

     to G
    G
    Full report
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
    Failure to: Respond appropriately to all alleged violations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Nutrition and Dietary Deficiency — F0814
    Failure to: Dispose of garbage and refuse properly.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0865
    Failure to: Have a plan that describes the process for conducting QAPI and QAA activities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Infection Control Deficiency — F0882
    Failure to: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Rights Deficiency — F0578
    Failure to: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0679
    Failure to: Provide activities to meet all resident's needs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0695
    Failure to: Provide safe and appropriate respiratory care for a resident when needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0761
    Failure to: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nutrition and Dietary Deficiency — F0803
    Failure to: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Environmental Deficiency — F0923
    Failure to: Have enough outside ventilation via a window or mechanical ventilation, or both.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0552
    Failure to: Ensure that residents are fully informed and understand their health status, care and treatments.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
    Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0676
    Failure to: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0688
    Failure to: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0693
    Failure to: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0758
    Failure to: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D

    Penalties

    $214K

    total fines

    A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
    Jun 15, 2022
    $116,357 fine
    Mar 28, 2022
    $33,348 fine
    Jan 24, 2022
    $3,976 fine
    No corresponding inspection report.
    Jan 20, 2022
    $31,320 fine
    Jan 17, 2022
    $3,646 fine
    No corresponding inspection report.
    Jan 10, 2022
    $3,250 fine
    No corresponding inspection report.
    Jan 3, 2022
    $2,948 fine
    No corresponding inspection report.
    Dec 27, 2021
    $2,620 fine
    No corresponding inspection report.
    Dec 6, 2021
    $2,275 fine
    No corresponding inspection report.
    Nov 29, 2021
    $1,965 fine
    No corresponding inspection report.
    Nov 22, 2021
    $1,625 fine
    No corresponding inspection report.
    Nov 15, 2021
    $1,300 fine
    No corresponding inspection report.
    Oct 28, 2021
    $9,750 fine