Cycle 1
Health 2025-01-16 · Fire 2025-01-16
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Aurora, CO
Hampden Hills Post Acute
2-star overall rating with 2-star inspections with 17 recent health deficiencies
14699 E Hampden Ave, Aurora, CO
(303) 693-0111
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
218
Certified beds
Average residents
196
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1977-05-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
716
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.99
Composite VBP score used to determine payment impact.
Payment multiplier
1.0193
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.54
Baseline 18.76% · Performance 17.47% · Measure score 8.54 · Achievement 8.54 · Improvement 6.93
Healthcare-associated infections
7.44
Baseline 5.70% · Performance 5.61% · Measure score 7.44 · Achievement 7.44 · Improvement 0.79
Total nurse turnover
8.18
Baseline 32.72% · Performance 30.26% · Measure score 8.18 · Achievement 8.18 · Improvement 2.62
Adjusted total nurse staffing
1.84
Baseline 4.21 hours · Performance 3.60 hours · Measure score 1.84 · Achievement 1.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.43% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 7.48% · Lower 95% interval 6.56% |
| Discharge to community | 42.31% |
50.57%
8.3 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 31.43% · Lower 95% interval 32.64% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.7% |
95.27%
3.4 pts better
|
Numerator 76 · Denominator 77 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 77 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 30 · Denominator 60 |
| Discharge mobility score | 38.33% |
50.94%
12.6 pts worse
|
Numerator 23 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 3.9% |
2.29%
1.6 pts worse
|
Numerator 3 · Denominator 77 · Adjusted rate 3.66% |
| Healthcare-associated infections requiring hospitalization | 5.61% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 1.52% · Lower 95% interval 3.01% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 256 |
| Staff flu vaccination coverage | 90.78% |
42%
48.8 pts better
|
Numerator 256 · Denominator 282 |
| Discharge function score | 48.33% |
56.45%
8.1 pts worse
|
Numerator 29 · Denominator 60 |
| Transfer of health information to provider | 90.48% |
95.95%
5.5 pts worse
|
Numerator 19 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 44.74% |
25.2%
19.5 pts better
|
Numerator 17 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.7
0.3 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
93.5%
2.4 pts better
|
93.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 99.5% · Q3 97.8% · Q4 92.8% · 4Q avg 95.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
94.7%
3.8 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.4%
0.9 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 1.6% · Q4 2.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.9% |
7.4%
15.5 pts worse
|
11.4%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 38.3% · Q3 21.1% · Q4 10.1% · 4Q avg 22.9% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
5.0%
1.8 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.4% · Q3 7.4% · Q4 5.2% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.2% |
11.2%
5 pts better
|
19.6%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 5.3% · Q3 6.9% · Q4 6.3% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.5% |
20.6%
1.1 pts better
|
16.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 22.4% · Q3 17.9% · Q4 15.9% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.0% |
15.2%
14.8 pts worse
|
16.3%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 57.5% · Q3 23.7% · Q4 4.6% · 4Q avg 30.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.6% |
14.6%
5 pts worse
|
14.9%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 43.4% · Q3 10.8% · Q4 3.7% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.8%
0.3 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.5%
0.3 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.9% · Q3 1.1% · Q4 1.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
22.4%
1.5 pts worse
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 26.5% · Q3 18.6% · Q4 27.2% · 4Q avg 23.9% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
3.7%
1.4 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 2.7% · Q4 2.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.2% |
76.4%
9.2 pts worse
|
81.7%
14.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 68.8% · Q3 66.4% · Q4 67.2% · 4Q avg 67.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
12.8%
7.8 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 5.9% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 1.8% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.6% |
75.6%
3 pts worse
|
79.7%
7.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
20.3%
3.2 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 25.0% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-27 · Fire 2023-07-27
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-17 · Fire 2022-06-17
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-16
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-16
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-16
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
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 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-02-14
D · Potential for more than minimal harm
2023-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-07-27
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-27
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-27
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 2023-08-25
E · Potential for more than minimal harm
2023-07-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-05
D · Potential for more than minimal harm
2023-07-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-27
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-27
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-07-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-27
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 2023-09-05
D · Potential for more than minimal harm
2023-07-27
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-09-12
C · Minimal harm
2023-07-27
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-08-25
E · Potential for more than minimal harm
2022-06-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-17
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-17
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-17
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-17
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-07-15
Penalties and ownership
What sits behind the stars
Ownership
Endura Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Converdia Health Staffing - Therapies
Operational/Managerial Control · Organization
Englade, Keith
Operational/Managerial Control · Individual
Goldberg, Sheldon
Operational/Managerial Control · Individual
Graham, Joseph
Corporate Officer · Individual
Jorgensen, David
Corporate Director · Individual
Keetch, Chad
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Springs At St Andrews Village, The
Aurora, CO
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of Aurora
Aurora, CO
4-star overall rating with 3-star inspections with $33,222 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Beth Israel At Shalom Park
Aurora, CO
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
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