Cycle 1
Health 2024-11-21 · Fire 2024-11-21
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Aurora, CO
Veterans Community Living Center At Fitzsimons
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
1919 Quentin St, Aurora, CO
(720) 857-6400
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
131
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.04
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.54
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.99
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.25
CMS adjusted RN staffing hours
Adjusted total hours
5.44
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
214
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
77.59
Composite VBP score used to determine payment impact.
Payment multiplier
1.0252
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.34
Performance 37.78% · Measure score 6.34 · Achievement 6.34 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
9.18
Baseline 4.23 hours · Performance 5.69 hours · Measure score 9.18 · Achievement 9.18 · Improvement 8.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.86% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 20% · Lower 95% interval 7.87% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.6 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 60% |
95.27%
35.3 pts worse
|
Numerator 12 · Denominator 20 |
| Falls with major injury | 5% |
0.77%
4.2 pts worse
|
Numerator 1 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 20 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 10.45% |
8.2%
2.2 pts better
|
Numerator 28 · Denominator 268 |
| Staff flu vaccination coverage | 96.5% |
42%
54.5 pts better
|
Numerator 248 · Denominator 257 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.3
0.5 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.8 · 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 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.0% |
93.5%
6.5 pts worse
|
93.4%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.8% · Q2 89.5% · Q3 87.7% · Q4 84.9% · 4Q avg 87.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.7%
3.9 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.4%
1.4 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.6% · Q3 4.9% · Q4 3.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
7.4%
3.6 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.5% · Q3 3.6% · Q4 2.7% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.0%
1.3 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.7% · Q3 3.7% · Q4 2.8% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
11.2%
0.8 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 12.4% · Q3 13.0% · Q4 10.1% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
20.6%
1.8 pts better
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 15.5% · Q3 26.8% · Q4 17.3% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.1%
0.7 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.8% · Q4 0.8% · 4Q avg 0.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.7% |
15.2%
6.5 pts worse
|
16.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 26.6% · Q3 22.3% · Q4 13.6% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
14.6%
5.4 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 22.7% · Q3 18.3% · Q4 19.6% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 8.7% |
0.8%
7.9 pts worse
|
1.0%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.1% · Q3 7.7% · Q4 7.8% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
1.5%
1.8 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 2.5% · Q3 3.3% · Q4 1.6% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.3% |
22.4%
1.9 pts worse
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 25.3% · Q3 21.7% · Q4 25.7% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
3.7%
0.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.6% · Q3 4.5% · Q4 3.1% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 36.9% |
76.4%
39.5 pts worse
|
81.7%
44.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 30.3% · Q3 34.9% · Q4 43.1% · 4Q avg 36.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.4% |
1.5%
3.9 pts worse
|
1.6%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q3 10.0% · Q4 0.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.6% |
75.6%
15 pts worse
|
79.7%
19.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-28 · Fire 2023-06-28
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Cycle 3
Health 2020-01-20 · Fire 2020-01-20
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-18
F · Potential for more than minimal harm
2024-11-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-20
F · Potential for more than minimal harm
2024-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-25
F · Potential for more than minimal harm
2024-11-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-17
F · Potential for more than minimal harm
2024-11-21
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-11-21
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-11-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-25
D · Potential for more than minimal harm
2024-11-21
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 2025-02-25
D · Potential for more than minimal harm
2024-11-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-22
F · Potential for more than minimal harm
2023-07-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-08-30
L · Immediate jeopardy
2023-06-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-06-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-09
F · Potential for more than minimal harm
2023-06-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-28
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-31
F · Potential for more than minimal harm
2023-06-28
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-03
F · Potential for more than minimal harm
2023-06-28
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-06-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-06-28
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-06-28
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-08-31
F · Potential for more than minimal harm
2020-01-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-03-03
F · Potential for more than minimal harm
2020-01-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-03
F · Potential for more than minimal harm
2020-01-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-11-21
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 2025-01-03
E · Potential for more than minimal harm
2024-11-21
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 2025-01-03
E · Potential for more than minimal harm
2024-11-21
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-21
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 2025-01-03
D · Potential for more than minimal harm
2024-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-11-21
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-01-03
J · Immediate jeopardy
2023-06-28
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 2023-08-01
F · Potential for more than minimal harm
2023-06-28
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-28
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-28
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-28
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 2023-08-01
D · Potential for more than minimal harm
2023-06-28
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2023-08-01
D · Potential for more than minimal harm
2020-01-20
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 2020-02-28
D · Potential for more than minimal harm
2020-01-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-03-20
Penalties and ownership
What sits behind the stars
$34,467
2023-07-28
Fine
Fine · fine $34,467
Fine
$45,000
2023-06-28
Fine
Fine · fine $45,000
Fine
Ownership
Hsu, Carrie
Operational/Managerial Control · Individual
Simmons, Ranell
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Aviva At Fitzsimons
Aurora, CO
3-star overall rating with 2-star inspections with $23,271 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
University Heights Care Center
Aurora, CO
2-star overall rating with 1-star inspections with abuse icon flag with $9,315 in total fines with 17 recent health deficiencies
#3
Highland Park Rehabilitation & Care Center
Aurora, CO
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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