Lowry Hills Care and Rehabilitation
10201 E 3rd Ave, Aurora, CO 80010 · Arapahoe County · 108 certified beds · avg 100 residents/day · certified since Sep 19, 1968
Part of chain: SWEETWATER CARE (8 facilities, chain avg rating 2.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 26, 2025 · F-0627 · triggered by a complaint
The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely.
Why it matters: A rushed or poorly planned move can leave a resident somewhere that can't meet their needs.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 27, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 6, 2023 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 8, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Oct 14, 2021 · F-0725
The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Why it matters: Understaffing means longer waits for help, missed care, and higher risk of falls and other harm.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Nov 12, 2021 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 14, 2021 · F-0550
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Why it matters: Being treated without dignity harms a resident's self-worth, mental health, and overall quality of life.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 12, 2021 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 14, 2021 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 6, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 14, 2021 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 6, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 14, 2021 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 12, 2021 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 14, 2021 · F-0760
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 12, 2021 (Deficient, Provider has date of correction)
All citations in the current public record (52)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 3, 2026 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jun 3, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 26, 2025 | ▲ G · Actual harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Apr 22, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| May 7, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · from a complaint |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| May 7, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 6, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 26, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Jan 26, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 14, 2021 | ▲ H · Actual harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Oct 14, 2021 | ▲ G · Actual harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Oct 14, 2021 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Oct 14, 2021 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Oct 14, 2021 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 14, 2021 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Oct 14, 2021 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Oct 14, 2021 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 14, 2021 | E · Potential for harm, repeated | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Oct 14, 2021 | E · Potential for harm, repeated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Oct 14, 2021 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Oct 14, 2021 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Oct 14, 2021 | E · Potential for harm, repeated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Oct 14, 2021 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Oct 14, 2021 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Oct 14, 2021 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Oct 14, 2021 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Oct 14, 2021 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Oct 14, 2021 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 14, 2021 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Oct 14, 2021 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 12).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 21 | 6 | H ▲ |
| 2023 | 11 | 1 | G ▲ |
| 2024 | 12 | 0 | E |
| 2025 | 6 | 1 | G ▲ |
| 2026 | 2 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $2,516.
| Date | Type | Amount / length |
|---|---|---|
| Dec 6, 2023 | Fine | $2,516 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.47 | 3.89 | 3.95 | bottom 35% in Colorado; bottom 35% in the U.S. |
| Registered Nurse hours | 0.60 | 0.86 | 0.69 | bottom 26% in Colorado; top 48% in the U.S. |
| Weekend total nurse staffing | 3.23 | 3.44 | 3.50 | bottom 45% in Colorado; bottom 43% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.44 | 0.61 | 0.48 | bottom 32% in Colorado; top 41% in the U.S. |
| Total nursing staff turnover (%) | 38.5 | 47.1 | 45.8 | top 27% in Colorado; top 32% in the U.S. |
| RN turnover (%) | 38.1 | 44.6 | 42.9 | top 37% in Colorado; top 44% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.30, RN 0.57, weekend 3.07. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Individual
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Chesley, Aaron | Individual | 5% or Greater Indirect Ownership Interest | 50% | 12/01/2017 |
| Sweetwater Care Opco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 12/01/2017 |
| Chesley, Aaron | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2017 |
| Medlock, Rebecca | Individual | W-2 Managing Employee | NOT APPLICABLE | 12/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Highland Park Rehabilitation & Care Center | 0.2 mi | Aurora, CO | ★★★★★ | 4/5 | |
| Center at Lowry, LLC | 1.1 mi | Denver, CO | ★★★☆☆ | 2/5 | |
| Hilltop Park Post Acute | 2.2 mi | Denver, CO | ★★☆☆☆ | 1/5 | |
| Veterans Community Living Center at Fitzsimons | 2.4 mi | Aurora, CO | ★★★☆☆ | 3/5 | |
| Berkley Manor Care Center | 2.4 mi | Denver, CO | ★★★★★ | 3/5 | |
| Crestmoor Care Center | 2.5 mi | Denver, CO | ★★★☆☆ | 2/5 | abuse |
| University Heights Care Center | 2.7 mi | Aurora, CO | ★★★☆☆ | 2/5 | abuse |
| Aviva at Fitzsimons | 2.9 mi | Aurora, CO | ★★★★☆ | 3/5 | |
| Garden Terrace Alzheimer's Center of Excellence | 3.1 mi | Aurora, CO | ★★★★☆ | 4/5 | |
| Advanced Health Care of Aurora | 3.3 mi | Aurora, CO | ★★★★★ | 4/5 | |
| Life Care Center of Aurora | 3.9 mi | Aurora, CO | ★★★★★ | 4/5 | |
| Holly Heights Care and Rehabilitation | 4.1 mi | Denver, CO | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 065001.