Cycle 1
Health 2024-10-24 · Fire 2024-10-24
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Aurora, CO
Advanced Health Care Of Aurora
5-star overall rating with 4-star inspections with $8,746 in total fines with 4 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
1800 S Potomac St, Aurora, CO
(720) 213-1700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advanced Health Care
Operator or chain grouping
Approved since
2007-12-20
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
26 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.21
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.27
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.13
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.49
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
1.12
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.35
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.76
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
387
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
70.93
Composite VBP score used to determine payment impact.
Payment multiplier
1.0228
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.11
Baseline 16.11% · Performance 17.67% · Measure score 8.11 · Achievement 8.11 · Improvement 0
Healthcare-associated infections
8.95
Baseline 5.72% · Performance 5.16% · Measure score 8.95 · Achievement 8.95 · Improvement 7.23
Total nurse turnover
7.70
Baseline 46.03% · Performance 32.20% · Measure score 7.70 · Achievement 7.70 · Improvement 6.03
Adjusted total nurse staffing
3.61
Baseline 4.43 hours · Performance 4.10 hours · Measure score 3.61 · Achievement 3.61 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 893 · Observed rate 9.07% · Lower 95% interval 8.88% |
| Discharge to community | 76.58% |
50.57%
26 pts better
|
Better than the National Rate · Eligible stays 839 · Observed rate 75.09% · Lower 95% interval 73.33% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.5% |
95.27%
3.2 pts better
|
Numerator 527 · Denominator 535 |
| Falls with major injury | 0.75% |
0.77%
About the same
|
Numerator 4 · Denominator 535 |
| Discharge self-care score | 77.55% |
53.69%
23.9 pts better
|
Numerator 304 · Denominator 392 |
| Discharge mobility score | 77.55% |
50.94%
26.6 pts better
|
Numerator 304 · Denominator 392 |
| Pressure ulcers or injuries, new or worsened | 1.87% |
2.29%
0.4 pts better
|
Numerator 10 · Denominator 535 · Adjusted rate 2.03% |
| Healthcare-associated infections requiring hospitalization | 5.16% |
7.12%
2 pts better
|
Better than the National Rate · Eligible stays 520 · Observed rate 3.85% · Lower 95% interval 3.87% |
| Staff COVID-19 vaccination coverage | 2.88% |
8.2%
5.3 pts worse
|
Numerator 3 · Denominator 104 |
| Staff flu vaccination coverage | 88.24% |
42%
46.2 pts better
|
Numerator 105 · Denominator 119 |
| Discharge function score | 79.34% |
56.45%
22.9 pts better
|
Numerator 311 · Denominator 392 |
| Transfer of health information to provider | 88.48% |
95.95%
7.5 pts worse
|
Numerator 361 · Denominator 408 |
| Transfer of health information to patient | 90.27% |
96.28%
6 pts worse
|
Numerator 102 · Denominator 113 |
| Resident COVID-19 vaccinations up to date | 52.51% |
25.2%
27.3 pts better
|
Numerator 136 · Denominator 259 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
76.4%
21.3 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 98.0% · Q3 97.5% · Q4 96.4% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
12.8%
5 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 7.6% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.0% · Q3 0.9% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.6% |
75.6%
18 pts better
|
79.7%
13.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
20.3%
0.8 pts worse
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 20.9% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-09 · Fire 2023-05-09
2 health deficiencies
Top issue: Infection Control (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-01-27 · Fire 2022-01-27
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-10-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-10-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-10-24
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-10-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-30
F · Potential for more than minimal harm
2024-10-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-10-24
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-10-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-10-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-30
E · Potential for more than minimal harm
2024-10-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-30
F · Potential for more than minimal harm
2023-05-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-06-17
F · Potential for more than minimal harm
2023-05-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-01
F · Potential for more than minimal harm
2023-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-27
F · Potential for more than minimal harm
2023-05-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-05-09
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-05-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-05-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-05-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-05-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-06-01
D · Potential for more than minimal harm
2022-01-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-02
D · Potential for more than minimal harm
2022-01-27
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-03-21
D · Potential for more than minimal harm
2022-01-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-21
D · Potential for more than minimal harm
2022-01-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-03-15
D · Potential for more than minimal harm
2022-01-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-02-28
D · Potential for more than minimal harm
2022-01-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-12
E · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-24
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-11-17
G · Actual harm
2023-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-26
E · Potential for more than minimal harm
2023-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-26
D · Potential for more than minimal harm
2022-01-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-02-09
Penalties and ownership
What sits behind the stars
$8,746
2023-05-09
Fine
Fine · fine $8,746
Fine
Ownership
New Ahc Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Advanced Health Care - Larry H Miller Corporation
5% Or Greater Indirect Ownership Interest · Organization
Himes, Cassidy
Operational/Managerial Control · Individual
Karen Gail Miller Irrev Tr Fbo Zane Miller
5% Or Greater Indirect Ownership Interest · Organization
Oxnam, Nathan
Corporate Officer · Individual
The G&H Miller Utah Trust Dated February 26, 2019
5% Or Greater Indirect Ownership Interest · Organization
The Gail Miller Gst Trust
5% Or Greater Indirect Ownership Interest · Organization
The Karen Gail Miller Irrevocable Trust For The Benefit Of Karen R. Wi
5% Or Greater Indirect Ownership Interest · Organization
The Karen Gail Miller Irrevocable Trust For The Benefit Of Roger L. Mi
5% Or Greater Indirect Ownership Interest · Organization
The Karen Gail Miller Irrevocable Trust For The Benefit Of Stephen F.
5% Or Greater Indirect Ownership Interest · Organization
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#3
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