Cycle 1
Health 2024-08-15 · Fire 2024-08-15
0 health deficiencies
No concentrated health issue counts in this cycle.
13 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Colorado Springs, CO
Advanced Health Care Of Colorado Springs
5-star overall rating with 5-star inspections with 13 fire-safety deficiencies in the latest cycle
55 S Parkside Dr, Colorado Springs, CO
(719) 418-4500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
34
Certified beds
Average residents
29
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advanced Health Care
Operator or chain grouping
Approved since
2013-08-12
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
1.43
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.60
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
6.35
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.75
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
5.00
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.45
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
4.74
CMS adjusted total nurse staffing hours
Case-mix index
1.83
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
540
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.04
Composite VBP score used to determine payment impact.
Payment multiplier
1.0213
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 15.85% · Performance 15.05% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
10
Baseline 4.28% · Performance 4.61% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
2.53
Baseline 64.71% · Performance 53.33% · Measure score 2.53 · Achievement 2.53 · Improvement 2.35
Adjusted total nurse staffing
4.68
Baseline 4.11 hours · Performance 4.41 hours · Measure score 4.68 · Achievement 4.68 · Improvement 1.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.91% |
10.72%
2.8 pts better
|
Better than the National Rate · Eligible stays 681 · Observed rate 5.87% · Lower 95% interval 6.29% |
| Discharge to community | 76.61% |
50.57%
26 pts better
|
Better than the National Rate · Eligible stays 591 · Observed rate 79.36% · Lower 95% interval 73.07% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.97% |
95.27%
2.7 pts better
|
Numerator 387 · Denominator 395 |
| Falls with major injury | 0.76% |
0.77%
About the same
|
Numerator 3 · Denominator 395 |
| Discharge self-care score | 55.33% |
53.69%
1.6 pts better
|
Numerator 166 · Denominator 300 |
| Discharge mobility score | 60.67% |
50.94%
9.7 pts better
|
Numerator 182 · Denominator 300 |
| Pressure ulcers or injuries, new or worsened | 1.53% |
2.29%
0.8 pts better
|
Numerator 6 · Denominator 391 · Adjusted rate 1.84% |
| Healthcare-associated infections requiring hospitalization | 4.61% |
7.12%
2.5 pts better
|
Better than the National Rate · Eligible stays 390 · Observed rate 2.56% · Lower 95% interval 2.65% |
| Staff COVID-19 vaccination coverage | 8.96% |
8.2%
0.8 pts better
|
Numerator 6 · Denominator 67 |
| Staff flu vaccination coverage | 78.49% |
42%
36.5 pts better
|
Numerator 73 · Denominator 93 |
| Discharge function score | 56.67% |
56.45%
0.2 pts better
|
Numerator 170 · Denominator 300 |
| Transfer of health information to provider | 94.59% |
95.95%
1.4 pts worse
|
Numerator 315 · Denominator 333 |
| Transfer of health information to patient | 83.02% |
96.28%
13.3 pts worse
|
Numerator 44 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 18.36% |
25.2%
6.8 pts worse
|
Numerator 38 · Denominator 207 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.4% |
76.4%
19 pts better
|
81.7%
13.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 95.6% · Q3 95.2% · Q4 95.2% · 4Q avg 95.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
12.8%
6.8 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.8% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.4% · Q3 0.5% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
75.6%
19 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
20.3%
1.2 pts worse
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 22.0% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-16 · Fire 2023-03-16
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-12-16 · Fire 2021-12-16
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-15
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-09-26
F · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-04
F · Potential for more than minimal harm
2024-08-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-26
F · Potential for more than minimal harm
2024-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-03
F · Potential for more than minimal harm
2024-08-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-02
D · Potential for more than minimal harm
2024-08-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-15
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2024-09-25
F · Potential for more than minimal harm
2023-03-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-03-16
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-28
F · Potential for more than minimal harm
2021-12-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-03-16
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 2023-04-07
D · Potential for more than minimal harm
2023-03-16
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
D · Potential for more than minimal harm
2021-12-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-12-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-01-12
D · Potential for more than minimal harm
2021-12-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-12
Penalties and ownership
What sits behind the stars
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
Beckman, Robert
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 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
Nearby options
Other facilities in reach
#1
Life Care Center Of Colorado Springs
Colorado Springs, CO
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Sunny Vista Living Center
Colorado Springs, CO
3-star overall rating with 3-star inspections with 6 recent health deficiencies
#3
Fountain View Rehabilitation And Nursing LLC
Colorado Springs, CO
1-star overall rating with 2-star inspections with $12,968 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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