Cycle 1
Health 2023-12-21 · Fire 2023-12-21
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Lakewood, CO
Ahc Of Lakewood, LLC
5-star overall rating with 4-star inspections with $72,634 in total fines with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
11155 W 15th Pl, Lakewood, CO
(720) 866-8400
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
36
Certified beds
Average residents
30
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advanced Health Care
Operator or chain grouping
Approved since
2022-08-31
CMS approved date
Coverage
Medicare + Medicaid
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
1.63
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.48
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
6.25
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
2.77
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
5.21
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.38
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.19
CMS adjusted RN staffing hours
Adjusted total hours
4.56
CMS adjusted total nurse staffing hours
Case-mix index
1.87
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,489
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.88
Performance 21.02% · Measure score 0.88 · Achievement 0.88 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.10
Performance 6.61% · Measure score 4.10 · Achievement 4.10 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Performance 70.49% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.43
Performance 4.34 hours · Measure score 4.43 · Achievement 4.43 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.22% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 436 · Observed rate 9.17% · Lower 95% interval 8.02% |
| Discharge to community | 74.06% |
50.57%
23.5 pts better
|
Better than the National Rate · Eligible stays 401 · Observed rate 71.07% · Lower 95% interval 70.07% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.7% |
95.27%
3.4 pts better
|
Numerator 304 · Denominator 308 |
| Falls with major injury | 0.65% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 308 |
| Discharge self-care score | 69.41% |
53.69%
15.7 pts better
|
Numerator 152 · Denominator 219 |
| Discharge mobility score | 69.41% |
50.94%
18.5 pts better
|
Numerator 152 · Denominator 219 |
| Pressure ulcers or injuries, new or worsened | 0.65% |
2.29%
1.6 pts better
|
Numerator 2 · Denominator 307 · Adjusted rate 0.68% |
| Healthcare-associated infections requiring hospitalization | 6.61% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 288 · Observed rate 5.9% · Lower 95% interval 4.5% |
| Staff COVID-19 vaccination coverage | 5% |
8.2%
3.2 pts worse
|
Numerator 4 · Denominator 80 |
| Staff flu vaccination coverage | 84.21% |
42%
42.2 pts better
|
Numerator 96 · Denominator 114 |
| Discharge function score | 69.86% |
56.45%
13.4 pts better
|
Numerator 153 · Denominator 219 |
| Transfer of health information to provider | 98.36% |
95.95%
2.4 pts better
|
Numerator 240 · Denominator 244 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 58 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 52.9% |
25.2%
27.7 pts better
|
Numerator 82 · Denominator 155 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.9% |
76.4%
13.5 pts better
|
81.7%
8.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 87.6% · Q3 90.4% · Q4 91.7% · 4Q avg 89.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
12.8%
2.3 pts better
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 10.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
75.6%
20.5 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
20.3%
5.9 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 25.9% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-31 · Fire 2022-08-31
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-12-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-22
F · Potential for more than minimal harm
2023-12-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-26
F · Potential for more than minimal harm
2023-12-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-03-23
F · Potential for more than minimal harm
2023-12-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-23
F · Potential for more than minimal harm
2023-12-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-27
F · Potential for more than minimal harm
2023-12-21
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 2024-01-22
E · Potential for more than minimal harm
2023-12-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-21
E · Potential for more than minimal harm
2023-12-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-05
D · Potential for more than minimal harm
2023-12-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-05
D · Potential for more than minimal harm
2023-12-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-12-21
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-12-21
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-21
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-01-08
D · Potential for more than minimal harm
2023-12-21
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-12-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-31
Penalties and ownership
What sits behind the stars
$4,545
2023-11-06
Fine
Fine · fine $4,545
Fine
$4,545
2023-10-30
Fine
Fine · fine $4,545
Fine
$4,545
2023-10-23
Fine
Fine · fine $4,545
Fine
$4,545
2023-10-17
Fine
Fine · fine $4,545
Fine
$4,545
2023-10-10
Fine
Fine · fine $4,545
Fine
$4,545
2023-10-02
Fine
Fine · fine $4,545
Fine
$4,587
2023-09-25
Fine
Fine · fine $4,587
Fine
$4,587
2023-09-18
Fine
Fine · fine $4,587
Fine
$4,545
2023-09-11
Fine
Fine · fine $4,545
Fine
$4,545
2023-09-05
Fine
Fine · fine $4,545
Fine
$4,235
2023-08-28
Fine
Fine · fine $4,235
Fine
$3,846
2023-08-21
Fine
Fine · fine $3,846
Fine
$3,496
2023-08-14
Fine
Fine · fine $3,496
Fine
$3,176
2023-08-07
Fine
Fine · fine $3,176
Fine
$7,409
2023-07-17
Fine
Fine · fine $7,409
Fine
$1,764
2023-06-26
Fine
Fine · fine $1,764
Fine
$3,174
2023-06-05
Fine
Fine · fine $3,174
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
Barnes, Deborah
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
Lakewood Villa
Lakewood, CO
3-star overall rating with 2-star inspections with abuse icon flag with $40,006 in total fines with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Western Hills Health Care Center
Lakewood, CO
5-star overall rating with 5-star inspections with 5 recent health deficiencies
#3
Allison Care Center
Lakewood, CO
2-star overall rating with 2-star inspections with abuse icon flag with $34,580 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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