Cycle 1
Health 2024-12-05 · Fire 2024-12-05
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Aurora, CO
Highland Park Rehabilitation & Care Center
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
500 Geneva St, Aurora, CO
(303) 364-9311
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sweetwater Care
Operator or chain grouping
Approved since
1983-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 2 health / 2 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
0.65
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.41
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.33
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
0.46
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.50
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
72%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 49% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.96% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 12.2% · Lower 95% interval 6.89% |
| Discharge to community | 53.19% |
50.57%
2.6 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 50% · Lower 95% interval 40.83% |
| Medicare spending per beneficiary | 0.63 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 68.18% |
53.69%
14.5 pts better
|
Numerator 15 · Denominator 22 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 12 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 18.07% |
8.2%
9.9 pts better
|
Numerator 30 · Denominator 166 |
| Staff flu vaccination coverage | 71.6% |
42%
29.6 pts better
|
Numerator 116 · Denominator 162 |
| Discharge function score | 72.73% |
56.45%
16.3 pts better
|
Numerator 16 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.35% |
25.2%
20.9 pts worse
|
Numerator 1 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.3
0.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
93.5%
2.3 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 100.0% · Q3 100.0% · Q4 93.8% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
94.7%
3.3 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.4%
1 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.1% · Q3 2.1% · Q4 3.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
7.4%
6.3 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 0.0% · Q4 2.2% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.0%
0.3 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.2% · Q3 7.1% · Q4 7.0% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.8% |
11.2%
7.4 pts better
|
19.6%
15.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.6% · Q3 4.7% · Q4 2.3% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
20.6%
10.9 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 7.1% · Q3 11.1% · Q4 10.9% · 4Q avg 9.7% · 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 | 2.2% |
15.2%
13 pts better
|
16.3%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.4% |
14.6%
10.2 pts better
|
14.9%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 2.5% · Q3 5.0% · Q4 2.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.5%
0.7 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
22.4%
3.2 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 26.9% · Q3 24.9% · Q4 11.7% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
3.7%
0.4 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 4.0% · Q4 5.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
76.4%
1.6 pts better
|
81.7%
3.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 58.8% · Q2 79.0% · Q3 86.0% · Q4 84.8% · 4Q avg 78.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.8% |
12.8%
About the same
|
12.0%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 14.3% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.5%
0.5 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 3.2% · 4Q avg 2.0% · 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 | 16.5% |
20.3%
3.8 pts better
|
23.9%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 19.0% · Expected 27.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-13 · Fire 2023-07-13
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-05-04 · Fire 2022-05-04
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-07
F · Potential for more than minimal harm
2024-12-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-07
E · Potential for more than minimal harm
2024-12-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-03
F · Potential for more than minimal harm
2023-07-13
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 2023-12-05
F · Potential for more than minimal harm
2023-07-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-10
E · Potential for more than minimal harm
2023-07-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-23
E · Potential for more than minimal harm
2023-07-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-13
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 2023-08-18
F · Potential for more than minimal harm
2022-05-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-01
F · Potential for more than minimal harm
2022-05-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-25
Inspection history
Recent health citations
G · Actual harm
2025-07-28
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 2025-07-29
D · Potential for more than minimal harm
2025-07-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-07-28
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 2025-07-29
F · Potential for more than minimal harm
2025-05-22
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-05-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-14
E · Potential for more than minimal harm
2024-12-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-06
C · Minimal harm
2024-12-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-04-17
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 2024-04-20
D · Potential for more than minimal harm
2024-04-17
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-04-20
E · Potential for more than minimal harm
2023-07-13
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 2023-08-30
E · Potential for more than minimal harm
2023-07-13
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 2023-08-12
E · Potential for more than minimal harm
2023-07-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-07-13
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-07-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-07-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-12
D · Potential for more than minimal harm
2023-07-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-12
D · Potential for more than minimal harm
2023-07-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-12
D · Potential for more than minimal harm
2023-07-13
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 2023-08-12
D · Potential for more than minimal harm
2023-07-13
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 2023-08-12
D · Potential for more than minimal harm
2023-07-13
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-08-12
F · Potential for more than minimal harm
2022-05-04
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 2022-06-10
Penalties and ownership
What sits behind the stars
$0
2023-08-02
Payment Denial
Payment Denial · denial start 2023-12-06 · 17 days
17 day denial
Ownership
Sweetwater Care Resource LLC
5% Or Greater Direct Ownership Interest · Organization
Ajc Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Bouzida, Nabil
Operational/Managerial Control · Individual
Chesley, Aaron
5% Or Greater Indirect Ownership Interest · Individual
Chesley, Aaron
Operational/Managerial Control · Individual
Gamett, James
5% Or Greater Indirect Ownership Interest · Individual
Gamett, James
Operational/Managerial Control · Individual
J&S Gamett Nevada Trust
5% Or Greater Indirect Ownership Interest · Organization
Jbg Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Reddy, Vikas
Operational/Managerial Control · Individual
Sweetwater Care Resource LLC
Operational/Managerial Control · Organization
Nearby options
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#2
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Denver, CO
2-star overall rating with 1-star inspections with $17,933 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Veterans Community Living Center At Fitzsimons
Aurora, CO
4-star overall rating with 3-star inspections with $79,467 in total fines with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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