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 Veterans Community Living Center At Fitzsimons during CMS and state inspections, most recent first.
The facility failed to maintain an effective infection prevention and control program, particularly in its water management program and wound care practices. The water management program lacked details on building water systems and monitoring measures for Legionella. Additionally, a nurse did not properly clean scissors used for wound care, using inappropriate wipes and not allowing sufficient contact time for disinfection. These deficiencies highlight significant lapses in maintaining a safe and sanitary environment.
The facility failed to protect residents from abuse, with incidents of physical and sexual abuse occurring among residents. A resident with a history of aggression was involved in a physical altercation with another resident, resulting in injuries. Additionally, a resident with cognitive impairments and a history of inappropriate sexual behavior engaged in non-consensual touching of another resident. The facility did not implement effective interventions or update assessments to prevent further abuse.
The facility failed to update care plans for several residents, omitting critical medications like anticoagulants and necessary skin treatments. This oversight affected residents with conditions such as cerebrovascular disease and pressure sores, highlighting a lack of communication and coordination among staff.
The facility failed to provide timely dental care for three residents, resulting in unresolved dental pain and discomfort. A resident with cognitive impairment had broken teeth and pain, but no referral was made. Another resident reported dental pain affecting her ability to drink cold water, yet no appointment was scheduled. A third resident experienced discomfort from missing denture teeth and was informed of high costs without further assistance. Staff interviews revealed scheduling issues and delays due to recent outbreaks.
A resident with limited mobility and cognitive impairments was unable to reach the call light, compromising dignity and self-determination. Despite requiring substantial assistance, the call light was placed out of reach, leading to feelings of loneliness and anger. Staff interviews revealed inconsistencies in call light placement, failing to accommodate the resident's needs.
A resident with Alzheimer's and Parkinson's diseases, at risk for pressure ulcers, had new skin abrasions on the buttocks that were not reported timely by a CNA. Despite a care plan including skin integrity measures, the CNA failed to notify the nurse, delaying medical response. Staff interviews confirmed the lapse in communication and reporting.
A facility failed to follow a physician's order for a resident with limited ROM due to multiple sclerosis and morbid obesity. Despite an order for the resident to use an exercise bike for knee pain, staff did not assist her, citing a lack of clearance and the need for a hoyer lift. The resident's care plan lacked documentation on her risk for limited ROM, and therapy sessions were time-constrained, potentially leading to deconditioning.
A resident with moderate cognitive impairments and nutritional risk was not provided meals according to his preferences, which included Mexican food and hot sauce. Despite care plan instructions, observations showed meals served without these preferences, and staff interviews confirmed the oversight.
Deficiencies in Water Management and Wound Care Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in its water management program (WMP) and wound care practices. The WMP did not adequately describe the building water systems or identify specific areas where Legionella could grow and spread. It also lacked details on how to monitor control measures to prevent Legionella and waterborne pathogen growth. The facility's Legionella Surveillance policy was found to be insufficient as it did not include specific facility locations such as water heaters, cooling towers, and medical devices, nor did it specify the frequency of cleaning and disinfection of these systems. Interviews with staff revealed a lack of awareness and understanding of the CDC's Legionella toolkit and the requirements for a comprehensive WMP. In the area of wound care, the facility failed to ensure that scissors used for wound care were cleaned in a sanitary manner. During an observation, a registered nurse (RN) was seen using scissors for wound care on a resident's heel wounds without cleaning them before placing them on a clean work surface. After the procedure, the RN used inappropriate wipes to clean the scissors and did not allow the required contact time for effective disinfection. The RN and the unit manager confirmed that the scissors were supposed to be cleaned with specific germicidal wipes and remain wet for a certain period, which was not followed in this instance. The facility's failure to adhere to proper infection control protocols in both the water management program and wound care practices highlights significant deficiencies in maintaining a safe and sanitary environment. The lack of a comprehensive WMP and the improper cleaning of medical equipment could potentially lead to the development and transmission of communicable diseases and infections within the facility.
Failure to Prevent Resident Abuse in LTC Facility
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving incidents of physical and sexual abuse among residents. Resident #60, with a history of physical aggression and cognitive impairments, was involved in a physical altercation with Resident #127, who also had a history of wandering and physical aggression. The altercation occurred in a common area and resulted in injuries to Resident #127. Despite previous incidents and known triggers, the facility did not implement timely and effective interventions to prevent the altercation or protect the residents involved. Additionally, the facility failed to prevent sexual abuse incidents involving Resident #92 and Resident #45. Resident #92, who had cognitive impairments and a history of inappropriate sexual behavior, entered Resident #45's room without consent and touched her inappropriately. A subsequent incident occurred in a public area where Resident #92 again touched Resident #45 without her consent. Despite previous incidents and known cognitive decline, the facility did not update assessments or implement effective interventions to prevent further abuse. The facility's policies and procedures for abuse prevention were not effectively implemented, as evidenced by the repeated incidents of abuse and the lack of personalized interventions for residents with known aggressive or inappropriate behaviors. Staff interviews revealed a lack of awareness and understanding of residents' triggers and the effectiveness of interventions, such as the use of stop signs to deter wandering. The facility's failure to adequately monitor and address the behaviors of residents with known risks contributed to the deficiencies observed.
Deficiencies in Care Plan Revisions and Implementation
Penalty
Summary
The facility failed to revise and review comprehensive care plans for five residents, leading to deficiencies in their care. Specifically, the care plans for three residents were not updated to reflect the use of anticoagulant medications, despite physician orders indicating their necessity. These residents had various medical conditions, including cerebrovascular disease and aortic aneurysm, which required the use of anticoagulants like Apixaban. The care plans were not revised to include these medications, which are considered high-risk drugs, as confirmed by the assistant director of nursing (ADON). Another resident's care plan did not include prescribed medications for antianxiety, opioids, and anticoagulants. This resident had multiple diagnoses, including heart disease and anxiety disorders, and was receiving several medications, such as Oxycodone and Lorazepam. The comprehensive care plan failed to address the use and monitoring of these medications, which are critical for managing the resident's health conditions. Additionally, the facility did not implement a skin treatment care plan for a resident who developed a pressure sore. Although there was a physician's order for wound dressings, the care plan was not updated to include this treatment. Interviews with staff revealed a lack of communication and awareness regarding the resident's skin condition, leading to the omission of necessary interventions in the care plan.
Failure to Provide Timely Dental Care for Residents
Penalty
Summary
The facility failed to provide necessary dental care for three residents, leading to deficiencies in their oral health management. Resident #81, who had impaired cognitive function due to a cerebrovascular accident, experienced broken teeth and pain while eating. Despite a nurse documenting the resident's complaint and notifying the social worker, there was no follow-up or referral to dental services, and the resident's care plan lacked a focus on oral needs. Interviews with the social service director and social worker revealed a lack of awareness about the urgency of dental referrals and scheduling issues with the contracted dentist. Resident #45, who was cognitively intact and had multiple sclerosis, reported dental pain affecting her ability to drink cold water. Although she informed the facility staff of her discomfort, no dental appointment was scheduled, and her pain was not documented in her care plan. The social services team and transportation department were responsible for scheduling appointments, but they were unable to explain why the resident's dental needs were not addressed. Resident #93, who was also cognitively intact, had missing teeth from his dentures, causing mouth discomfort. Despite reporting this to the staff, he was informed of a high cost for new dentures without further assistance. The resident's care plan noted the denture issue but did not indicate any follow-up. Staff interviews highlighted delays in dental appointments due to recent COVID-19 and influenza outbreaks, which affected the availability of the in-house dentist.
Resident Dignity Compromised by Inaccessible Call Light
Penalty
Summary
The facility failed to ensure the dignity and self-determination of a resident with limited range of motion by not placing the call light within reach. The resident, who was over 65 years old and had diagnoses including Alzheimer's disease, Parkinson's disease, and neurocognitive disorder with Lewy bodies, was unable to reach the call light placed on the tray table. This was observed during interviews and visits, where the resident expressed frustration and feelings of loneliness and anger due to the inability to summon help when needed. The resident required substantial assistance with activities of daily living due to his medical conditions, which included left-sided weakness. Despite this, the call light was consistently placed out of reach, requiring the resident to roll over to activate the wall button or call out for help. The care plan indicated the need for total assistance, yet the placement of the call light did not accommodate the resident's limited mobility. Interviews with staff, including a registered nurse, certified nurse aides, and the assistant director of nursing, revealed inconsistencies in the understanding and implementation of call light placement. While some staff believed the resident could reach the call light on the tray table, others acknowledged the need for it to be placed on the resident's chest or within easy reach. The lack of a standardized approach led to the resident's inability to access the call light, compromising his dignity and self-determination.
Failure to Report Skin Alterations Timely
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA) reported new skin alterations for Resident #65 in a timely manner. Resident #65, who was over 65 years old and had diagnoses including Alzheimer's disease, Parkinson's disease, and neurocognitive disorder with Lewy bodies, was at risk for developing pressure ulcers. The resident required substantial assistance with daily activities and had a history of moisture-associated skin damage (MASD) to the buttocks. On November 21, 2024, during a wound observation, several small excoriated, shallow abrasion areas were noted on the resident's buttocks, which were not previously reported by the CNA to the nursing staff. The care plan for Resident #65, which was revised on the same day, included interventions such as alternating pressure air therapy, frequent repositioning, and notifying the medical doctor of any changes in skin integrity. Despite these measures, the CNA failed to report the new skin issues to the nurse on duty, which delayed the necessary medical response. The registered nurse (RN) and unit manager (UM) were unaware of the resident's new skin condition until the observation on November 21, 2024. Interviews with the staff revealed that the CNA was aware of the open area on the resident's bottom but did not report it immediately. The RN and UM confirmed that CNAs were responsible for reporting any skin changes to the nurse, who would then notify the wound doctor. The assistant director of nursing (ADON) stated that the weekly skin assessments did not indicate any issues prior to the observation, highlighting a lapse in communication and timely reporting by the CNA.
Failure to Follow Physician's Order for Resident's ROM Therapy
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM. The resident, under 65 years old, was diagnosed with multiple sclerosis, mild cognitive impairment, major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, and morbid obesity. Despite a physician's order dated September 6, 2024, for the resident to use the facility's exercise bike for knee pain, the order was not followed. The resident expressed difficulty in bending and flexing her knees and reported that staff did not assist her with ROM exercises. She was informed by the therapy team that she was not cleared to use the exercise bike, contradicting the existing physician's order. Interviews with staff revealed a lack of clarity and communication regarding the resident's therapy services. RN #1 was unsure of the specific services the resident received, while the physical therapist stated that residents requiring a hoyer lift could not use the exercise bikes, despite the physician's order. The restorative manager confirmed the limitation and mentioned that the resident's maintenance plan included using a standing table instead. The resident's care plan lacked documentation addressing her risk for limited ROM due to her diagnoses, and the facility's therapy sessions were constrained by time, potentially contributing to the resident's deconditioning.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated the preferences of a resident, identified as Resident #10, who was over 65 years old and had diagnoses including unspecified osteoarthritis, dementia, and protein-caloric malnutrition. The resident had moderate cognitive impairments and required assistance with various activities, including meal setup. Despite the care plan indicating that the resident was at risk for nutritional weight loss and should be offered food choices, including Mexican food and hot sauce with meals, these preferences were not consistently met. Observations revealed that the resident was served meals that did not align with his documented preferences. On one occasion, he was given a grilled cheese sandwich without hot sauce, and on another, he received chicken nuggets with gravy over fries, again without the requested hot sauce or a coke. Interviews with the registered dietitian and dietary manager confirmed that the resident liked Mexican food and should have been offered it regularly, with hot sauce available at each meal. However, these preferences were not consistently honored, leading to a deficiency in accommodating the resident's dietary preferences.
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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) |
|---|---|---|---|---|
| Aviva At Fitzsimons | 0.6 mi | ★★★★★ | 1 | 0 |
| University Heights Care Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Highland Park Rehabilitation & Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Lowry Hills Care And Rehabilitation | 2.4 mi | ★★★★★ | 0 | 0 |
| Center At Lowry, Llc | 3.2 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.