Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviva At Fitzsimons during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring that an area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
A resident with complex medical conditions experienced a significant change in condition, but the facility failed to monitor the resident's vital signs as per the nurse practitioner's orders. The resident's heart rate and blood pressure dropped significantly, and there was no documentation of consistent monitoring or notification to the nurse practitioner about the decline. Interviews with staff revealed a lack of adherence to physician's orders and inadequate documentation, contributing to the deficiency.
The facility failed to submit accurate direct care staffing data to the CMS PBJ system, resulting in an erroneous one-star rating due to a third-party processor's delay. Despite the PBJ report indicating low weekend staffing, a review of staff time cards showed no such issue.
The facility failed to conduct annual performance reviews for four CNAs, as required by their policy. This deficiency was identified through record reviews and staff interviews, which showed that the facility did not complete the necessary evaluations to determine training needs. The nursing home administrator acknowledged the oversight and mentioned plans to implement a new system to ensure evaluations are conducted in the future.
The facility failed to handle ready-to-eat foods in a sanitary manner, as observed during a dinner meal service. Cooks used the same gloves for multiple tasks, including handling food and non-food items, without changing gloves, contrary to regulations. The dietary manager acknowledged the need for improved hand hygiene practices.
The facility failed to maintain an effective infection control program, with housekeeping staff not following proper cleaning protocols and an LPN not wearing appropriate PPE during G-tube medication administration for a resident on Enhanced Barrier Precautions. Observations showed lapses in disinfecting high-touch areas and improper glove use, while interviews confirmed a lack of adherence to facility policies.
A facility reported a medication error rate of 6.06%, exceeding the acceptable threshold. An LPN administered an incorrect dosage of Lactaid to a resident due to stock limitations, and another LPN failed to administer Flonase to a resident because it was unavailable. Staff interviews revealed that established protocols for medication administration were not followed, contributing to the errors.
The facility failed to implement its policy on the use and storage of foods brought by family and visitors, leading to unsafe storage in a resident's refrigerator. Expired and undated food items were found, and temperature logs were not consistently filled out. The dietary manager acknowledged the oversight, noting that previous staff had been more consistent in checking the refrigerator.
Two residents experienced significant delays in call light responses, compromising their dignity and care. One resident, with chronic respiratory failure and ALS, faced extended wait times despite grievances and care plans emphasizing prompt assistance. Another resident, with COPD and hemiplegia, reported increased delays following a shift change. Staff cited device malfunctions and staffing challenges as contributing factors.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could lead to accidents, and that supervision measures in place were insufficient to prevent such incidents. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Monitor Resident's Condition and Follow Physician's Orders
Penalty
Summary
The facility failed to provide services according to professional standards of practice for a resident who experienced a significant change in condition. The resident, who was under 65 years old and had multiple complex medical conditions including acute and chronic respiratory failure, cerebral palsy, and chronic atrial fibrillation, was not consistently monitored as per the nurse practitioner's orders. The resident's heart rate and blood pressure dropped significantly, yet there was no documentation indicating that these vital signs were monitored every 30 minutes as ordered. The nurse practitioner had given a new order for a STAT EKG, a CBC in the morning, and to check the resident's blood pressure and heart rate every 30 minutes until the heart rate stabilized above 50. However, the electronic medical record did not show that the nursing staff followed these orders. Additionally, when the resident's condition continued to deteriorate, there was no documentation that the nurse practitioner was notified of the ongoing decline in the resident's blood pressure. Interviews with staff, including LPNs and the Director of Nursing, revealed that there was a lack of adherence to the physician's orders and inadequate documentation of the resident's condition. The Director of Nursing acknowledged that the nurse should have documented the monitoring of the resident's condition and notified the nurse practitioner of the decline. The failure to follow the physician's orders and properly document the resident's condition contributed to the deficiency identified in the facility's care practices.
Inaccurate PBJ Submission Leads to Erroneous Staffing Report
Penalty
Summary
The facility failed to ensure the mandatory submission of direct care staffing data based on payroll information to the CMS Payroll-Based Journal (PBJ) system. During the review of records, it was found that the PBJ staffing report for the third quarter of 2024 indicated excessive low weekend staffing, which contributed to the facility receiving a one-star rating. However, upon reviewing the facility's staff time cards from April to June 2024, it was revealed that the facility did not actually have low weekend staffing. In an interview, the Nursing Home Administrator (NHA) explained that the facility used a third-party processor to submit their PBJ report. The NHA stated that the third-party processor failed to submit the report on time, resulting in its rejection. This delay in submission led to the inaccurate one-star rating and the erroneous low weekend staffing trigger.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for four out of five certified nurse aides (CNAs), specifically CNA #2, CNA #3, CNA #4, and CNA #5. This deficiency was identified through record reviews and staff interviews, which revealed that the facility did not complete the required performance evaluations to determine potential training needs for these CNAs. The facility's policy mandates that all nurse aide personnel participate in regular in-service education, which should be based on the outcomes of these annual performance reviews. However, the facility was unable to provide documentation of such evaluations or subsequent in-service education for the CNAs in question. During an interview, the nursing home administrator acknowledged that the annual performance evaluations had not been completed for the CNAs. The administrator mentioned that the facility was in the process of implementing a new system where human resources would generate a list of CNAs requiring evaluations, which would then be completed by each manager. This process was intended to ensure that evaluations were conducted and reviewed before being finalized with the staff, but at the time of the survey, this system had not yet been put into practice.
Sanitation Deficiency in Food Handling
Penalty
Summary
The facility failed to ensure that ready-to-eat foods were handled in a sanitary manner in the main kitchen, leading to potential cross-contamination. During observations of the dinner meal service, it was noted that Cook #1 used the same pair of gloves to handle various items, including meal tickets, plate warmers, a door handle, and serving utensils, before touching food items such as chicken breast, bread, and french fries. Similarly, Cook #2 used the same gloves to handle cold storage doors, containers of lettuce, chopped red onion, tortilla strips, and egg salad, without changing gloves between tasks. These actions were contrary to the Colorado Retail Food Establishment Regulations, which require food employees to avoid bare-hand contact with ready-to-eat foods and to change gloves between tasks. The dietary manager acknowledged during an interview that the dietary staff should handle ready-to-eat food with gloves and clean utensils, and that gloves should be changed when starting a new task. The manager also noted that one of the cooks was new to the role and was still learning proper hand hygiene practices. Despite the facility's policy on food handling, which emphasizes frequent handwashing and adherence to sanitation guidelines, the observed practices did not align with these standards, resulting in the cited deficiency.
Infection Control Deficiencies in Housekeeping and PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed in the housekeeping practices on one of the units. Housekeeping staff did not follow appropriate infection control procedures when cleaning and disinfecting residents' rooms and high-touch areas such as call lights, door handles, and handrails. Observations revealed that a housekeeper did not use disinfectant on high-touch surfaces and failed to allow the disinfectant to remain on surfaces for the required dwell time to ensure germ elimination. Additionally, the housekeeper did not change gloves or perform hand hygiene after cleaning residents' toilets, and mopped floors with plain water instead of a disinfectant solution. Interviews with the housekeeping staff and management confirmed these lapses in protocol. The housekeeper admitted to not knowing what high-touch surfaces were and typically wore the same gloves throughout the cleaning process. The housekeeping and laundry manager acknowledged that the housekeeper should have cleaned from clean to dirty, disinfected all surfaces, and adhered to the disinfectant's dwell time. The director of nursing and the infection preventionist also confirmed that the facility's cleaning procedures were not followed, emphasizing the importance of daily cleaning and disinfection, especially for high-touch surfaces in rooms with medically complex residents. In another instance, the facility failed to ensure that staff wore appropriate personal protective equipment (PPE) when administering medications through a feeding tube for a resident on Enhanced Barrier Precautions (EBP). An LPN administered medications via a G-tube without wearing a gown, mask, or face shield, despite the resident being on EBP. The LPN believed that PPE was only necessary during wound care, contrary to the facility's policy, which requires PPE during high-contact activities, including G-tube medication administration. Interviews with other staff, including the unit manager and the infection preventionist, confirmed that PPE should have been worn to prevent infection spread.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported rate of 6.06%, resulting from two errors out of 33 opportunities. The first error involved a Licensed Practical Nurse (LPN) administering an incorrect dosage of Lactaid to a resident. The resident's Medication Administration Record (MAR) indicated a physician's order for Lactaid 3000 units via nasogastric tube, but the LPN dispensed a 9000-unit tablet, which was 6000 units more than prescribed. Upon realizing the mistake, the LPN attempted to cut the tablet in half, which still resulted in an incorrect dosage of 4500 units. The LPN acknowledged the error and noted that the facility only had 9000-unit tablets in stock, which led to the resident not receiving the medication as ordered. The second error involved another LPN who was unable to administer Flonase to a different resident due to the medication being unavailable. The resident's MAR showed a physician's order for Flonase suspension, 50 microgram/actuation, two inhalations in both nostrils every 12 hours. The LPN documented that the medication was on order with the pharmacy but did not administer it as prescribed. This failure to provide the medication as ordered contributed to the facility's medication error rate exceeding the acceptable threshold. Interviews with staff, including the unit manager and the Director of Nursing (DON), revealed that there were established protocols for handling medication administration, such as not cutting unscored tablets and contacting the physician if a medication was unavailable. However, these protocols were not followed in the incidents described, leading to the medication errors. The staff acknowledged the importance of adhering to these protocols to ensure accurate and safe medication administration.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors, specifically in ensuring safe and appropriate storage of food items in personal resident refrigerators. The Colorado Retail Food Establishment Regulations require that refrigerated, ready-to-eat time/temperature control for safety food be clearly marked with a date or day by which the food shall be consumed or discarded. The facility's policy mandates that perishable foods be stored in resealable containers with tightly fitting lids, labeled with the resident's name, the item, and the use-by date, and that nursing staff discard perishable foods on or before the use-by date. Observations and interviews revealed that the facility did not adhere to these policies. A resident reported that her refrigerator had not been checked by dietary staff in months, and her daughter had to defrost the refrigerator and discard expired food items. However, multiple expired items remained, including croutons, salad dressing, barbeque sauce, and cocktail sauce, along with undated items like zucchini bread and chocolate pudding. Additionally, there were dead gnats or fruit flies inside the refrigerator, and temperature logs were not consistently filled out. The dietary manager acknowledged the oversight and noted that a previously employed cook had been consistent in checking the refrigerator, but current staff had not maintained this practice.
Delayed Call Light Responses Compromise Resident Dignity
Penalty
Summary
The facility failed to ensure timely response to call lights, compromising the dignity and care of two residents. Resident #32, a younger individual with chronic respiratory failure and amyotrophic lateral sclerosis, was cognitively intact but dependent on staff for all activities of daily living. Despite having a care plan that emphasized the importance of prompt response to call lights, Resident #32 experienced significant delays, with call lights being activated for extended periods, sometimes exceeding 40 minutes. The resident and their representative reported that call lights were often turned off without assistance being provided, and grievances filed regarding these delays did not result in improvements. Resident #3, an elderly individual with chronic respiratory failure, COPD, and hemiplegia, also experienced delays in call light responses. This resident, who was cognitively intact and dependent on staff for most activities of daily living, reported that the change from 12-hour to 8-hour nursing shifts seemed to have affected the timeliness of call light responses. The resident noted that it often took 15 to 20 minutes for call lights to be answered, and sometimes multiple activations were necessary before receiving assistance. Staff interviews revealed that the facility's call light system was intended to notify staff via cell phones and pagers, but there were issues with the functionality of these devices. CNAs reported being overwhelmed with tasks, leading to delays in responding to call lights. The facility's goal was to answer call lights within five to ten minutes, but staffing challenges, including reliance on agency staff unfamiliar with the residents, contributed to longer response times. The facility's administration acknowledged these issues, noting that the call light system's notifications were not always reliable, and there were instances of staff not adhering to the protocol of leaving call lights on if they could not immediately meet a resident's needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Veterans Community Living Center At Fitzsimons | 0.6 mi | ★★★★★ | 0 | 0 |
| University Heights Care Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Highland Park Rehabilitation & Care Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Lowry Hills Care And Rehabilitation | 2.9 mi | ★★★★★ | 0 | 0 |
| Center At Lowry, Llc | 3.8 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.