Advanced Health Care of Aurora

Pharmacy Service Deficiencies

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.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure medical gas and vacuum systems have documented maintenance programs.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Construction Deficiencies

Meet requirements for sections of health care facilities separated by fire resistive construction.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Provide properly protected cooking facilities.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Pharmacy Service Deficiencies

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.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

A complaint survey, prompted by #CO1939628, #CO2567148, #CO2581499 and #CO2670402 was conducted on 11/19/25 to 11/20/25. One deficiency was cited. Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards in one out of three medication carts. Specifically, the facility failed to ensure the medication cart was locked when not in the direct line of sight of a nurse. Findings include:I. Facility policy and procedureThe Medication storage policy, revised September 2022, was provided by the director of nursing (DON) on 11/20/25 at 2:40 p.m. It read in pertinent part, “Only licensed nurses and pharmacy personnel are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.” II. ObservationsMedication cart #5 was observed on 11/19/25 at 1:26 p.m. with registered nurse (RN) #2. RN #2 walked up to the medication cart by the nurses’ station and tugged on the top drawer which opened. She pushed the drawer back and pushed the lock in with her hand locking the cart. She said the cart was not locked correctly and the cart should be locked at all times. Medication cart #5 was observed on 11/19/25 at 2:18 p.m. The cart was unlocked and unattended. There were residents and housekeeping personnel around the medication cart. The medication cart was by the nurses’ station. There was one unidentified staff member sitting at the station facing a computer screen. He was sitting with his back to the cart. At 2:21 p.m. RN #3 walked up to the cart. RN #3 opened and closed a drawer then he charted on the screen. After charting, he walked across the nurses’ station leaving the cart unlocked. He returned to the cart at 2:27 p.m. when he locked the cart by pushing the locking mechanism in. III. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 11/19/25 at 2:54 p.m. LPN #2 said medication carts should be locked when unattended for the safety of others. She said it was a crucial part of the job to keep medication locked. She said it was important since there was heavy traffic in the hallway from visitors, residents, an..

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the conti.. Based on observation and record review during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 ofthe Life Safety Code and the referenced NFPA 110, Sta.. Based on observation and staff interview during the course of the survey it was determined the med gas systems was not maintained IAW NFPA 99.No Medical gas report at time of the inspection.5.1.14.2.1* General.Health care facilitie.. Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3 Room 712 has a significant ga.. Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the kitchen cooking appliance locations in accordance with National Fire Protection Association (NFPA) Standard 96. This .. Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain firewalls in accordance with NFPA 101, 8.3.1.2. nal1. Storage room and rated room penetrations lost and found2. Th.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. Ice and snow in the east pat.. Based on observation and staff interviews, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105Records were not available at the time of the survey to document.. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:Oxygen Transfill rooms need a vent 12" of the .. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. Fire drills closer than an hour apart, not at varied times2. No 1st shift 4th quarter.NF.. The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of t.. Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13.1. Therapy-painted sprinkler heads 62.704 painted.. Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. This was evidenced by:1) Emergency Exit Lighting no annual a..

A recertification survey was conducted from 10/21/24 to 10/24/24. Three deficiencies were cited. An Emergency Preparedness survey was conducted from 10/21/24 to 10/24/24. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure the residents were offered hand hygiene before meals in the dining room and during the delivery of room trays; and,-Ensure point of care (POC) testing supplies were not contaminated from room to room. Findings include:I. Failed to ensure hand hygiene was offered to residents prior to mealsA. Professional referenceAccording to the Centers for Disease Control and Prevention' s (CDC) Hand Hygiene in Healthcare settings, revised 2/27/24, was retrieved on 10/28/24 from https://w.. Based on observations, record review, and interviews, the facility failed to ensure proper storage of medications in the medication storage room and in one of three medication storage carts.Specifically, the facility failed to:-Discard medications from the medication cart that had been discontinued;-Remove loose pills from drawer of a medication cart; and,-Ensure the temperature of the medication refrigerator was assessed, documented and addressed as needed. Findings include:I. Facility policy and procedureThe Medication Storage policy, revised September 2021, was provided by the nursing home administrator (NHA) on 10/21/24 at 6:06 p.m. The policy, in pertinent part, contained the following information:-"Medications and biologicals are stored safely, securely, and properly, following manufacturer' .. Based on record review and interviews, the facility failed to develop a comprehensive care plan for services that were provided in order to to attain the resident' s highest practicable physical, mental, and psychosocial well-being and to provide effective and person-centered care for three (#4, #11 and #26) of 13 residents out of 37 sample residents.Specifically, the facility failed to:-Ensure the comprehensive care plan addressed Resident #4' s pressure ulcer;-Ensure the comprehensive care plan addressed Resident #11' s changes related to her feeding tube, diet, intravenous (IV) antibiotics and fall interventions; and,-Ensure the comprehensive care plan addressed Resident #26' s pressure ulcer.Findings include:I. Facility policy and procedureThe Care Planning policy, undated, was provided by th..