Inspection Reports for
University Heights Care Center
656 DILLON WAY, AURORA, CO, 80011-6803
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 16, 2025
Visit Reason
The inspection was conducted due to complaints of abuse, misappropriation of funds, and pest control issues at University Heights Care Center.
Complaint Details
The complaint investigation substantiated physical abuse of Resident #6 by CNA #7 and found inadequate investigation of misappropriation of funds allegations involving Residents #1 and #4. The pest control issues were also confirmed through observations and resident interviews.
Findings
The facility failed to protect a resident from physical abuse by a certified nurse aide, failed to thoroughly investigate allegations of misappropriation of funds for two residents, and failed to maintain an effective pest control program resulting in a cockroach infestation throughout the facility.
Deficiencies (3)
F 0600: The facility failed to protect Resident #6 from physical abuse by CNA #7 despite the resident's repeated requests to stop care.
F 0610: The facility failed to conduct a thorough investigation into alleged misappropriation of funds for Residents #1 and #4, lacking documentation of staff interviews and financial reviews.
F 0925: The facility failed to maintain an effective pest control program, resulting in persistent cockroach infestations in multiple areas including the kitchen, resident rooms, and shower rooms.
Report Facts
Residents in sample: 18
Unauthorized Uber Eats transaction amount: 375
Cockroach trap size: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nurse Aide | Named in physical abuse finding involving Resident #6 |
| Social Services Director | Conducted investigations into abuse and misappropriation allegations | |
| Nursing Home Administrator | NHA | Provided facility policies and interviewed regarding investigations |
| Business Office Manager | Interviewed regarding misappropriation of funds investigations | |
| Dietary Manager | DM | Interviewed regarding pest control issues |
| Maintenance Director | MTD | Interviewed regarding pest control and cockroach infestation |
Inspection Report
Routine
Deficiencies: 11
Date: Aug 7, 2025
Visit Reason
Routine state inspection survey to assess compliance with regulatory requirements and quality of care at University Heights Care Center.
Findings
The facility was found deficient in multiple areas including failure to obtain consent for psychotropic medication, inadequate assistance with activities of daily living, failure to provide personalized activity programs, improper pressure ulcer care, medication errors, improper catheter care, failure to provide trauma-informed care, and infection control deficiencies.
Deficiencies (11)
F 0552: The facility failed to obtain consent prior to administration of an antipsychotic antidepressant medication for Resident #16.
F 0676: The facility failed to ensure Resident #59 consistently received assistance with personal hygiene and failed to provide language communication tools for Resident #63.
F 0677: The facility failed to ensure Resident #14 consistently received assistance with dining.
F 0679: The facility failed to provide personalized activity programs for Residents #63 and #31, including activities in their preferred language.
F 0686: The facility failed to provide appropriate pressure ulcer care for Resident #38, including failure to reposition and improper air mattress settings.
F 0690: The facility failed to ensure proper catheter care for Resident #2, including positioning catheter tubing and bag below the bladder.
F 0699: The facility failed to complete trauma-informed assessments and develop care plans for Resident #82 with PTSD prior to survey.
F 0760: The facility failed to ensure Resident #42 was administered the correct insulin dose by properly priming the insulin pen before administration.
F 0761: The facility failed to label medications with the date opened and failed to remove expired medications from medication carts.
F 0849: The facility failed to ensure hospice care notes for Resident #14 were readily accessible to facility staff for effective care coordination.
F 0880: The facility failed to maintain an infection control program including failure to follow enhanced barrier precautions, hand hygiene during medication administration and room cleaning, and proper storage of urine collectors.
Report Facts
Medication doses: 24
Pressure ulcer measurements: 4.6
Pressure ulcer measurements: 3.4
Pressure ulcer measurements: 0.3
BIMS score: 10
BIMS score: 12
BIMS score: 11
BIMS score: 13
BIMS score: 12
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Administered insulin to Resident #42 without priming the insulin pen and failed to perform hand hygiene between glove changes |
| LPN #1 | Licensed Practical Nurse | Observed with unlabeled inhalers and expired medications on medication cart |
| LPN #2 | Licensed Practical Nurse | Observed with unlabeled inhalers and expired medications on medication cart |
| CNA #5 | Certified Nurse Aide | Named in findings related to Resident #14 hospice care and Resident #38 wound care |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, wound care, trauma care, and hospice coordination |
| ADON | Assistant Director of Nursing | Interviewed regarding catheter care, trauma care, and medication storage |
| IP | Infection Preventionist | Interviewed regarding infection control program deficiencies |
| Social Worker Quality Mentor | Interviewed regarding trauma-informed care and psychotropic medication consent |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 26, 2025
Visit Reason
The inspection was conducted to investigate complaints of physical abuse and inadequate supervision at University Heights Care Center.
Complaint Details
The complaint investigation substantiated multiple incidents of resident-to-resident physical abuse and inadequate supervision leading to elopement. Resident #7 was substantiated as an aggressor in an incident on 2/12/25. Resident #2 was substantiated as an aggressor in incidents on 1/2/25 and 2/26/25. Resident #4 eloped on 3/2/25 and the facility failed to properly investigate or report the incident.
Findings
The facility failed to prevent physical abuse incidents involving multiple residents and did not provide adequate supervision to prevent elopement. Additionally, the facility failed to implement person-centered interventions to manage a resident's dementia-related aggressive behaviors.
Deficiencies (3)
F0600: The facility failed to protect residents from physical abuse by other residents, including incidents involving Resident #2, Resident #7, and others.
F0689: The facility failed to provide adequate supervision to prevent elopement and did not thoroughly investigate Resident #4's elopement on 3/2/25.
F0744: The facility failed to provide appropriate treatment and services to Resident #2 with dementia to prevent physically aggressive behaviors toward other residents.
Report Facts
Residents reviewed: 13
Residents reviewed for accidents: 12
Residents affected: 3
Residents affected: 1
Residents affected: 1
BIMS scores: 11
BIMS scores: 12
BIMS scores: 12
BIMS scores: 13
BIMS scores: 10
BIMS scores: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding Resident #7 and Resident #6 altercation and assessments |
| CNA #2 | Certified Nurse Aide | Interviewed regarding Resident #7 and Resident #6 behaviors and incident |
| Social Services Director | Interviewed regarding Resident #7 and Resident #6 incident and behaviors | |
| Director of Nursing | DON | Interviewed regarding Resident #7 and Resident #6 incident and care |
| CNA #3 | Certified Nurse Aide | Interviewed regarding Resident #2's aggressive behaviors |
| RN #3 | Registered Nurse | Interviewed regarding Resident #2's behaviors and staff interventions |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #4's elopement risk and supervision |
| RN #1 | Registered Nurse | Interviewed regarding Resident #4's elopement and supervision |
| Nursing Home Administrator | NHA | Interviewed regarding incidents, policies, and facility responses |
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Jan 24, 2024
Visit Reason
Annual recertification survey of University Heights Care Center to assess compliance with regulatory requirements including resident care, infection control, nutrition, and facility operations.
Findings
The facility was found deficient in multiple areas including medication self-administration assessment, provision of linens, grievance follow-up, resident abuse prevention, discharge planning, vision services, pain management, food service quality and safety, immunization administration and documentation, infection control, and quality assurance program implementation.
Deficiencies (16)
F 0554: Facility failed to ensure Resident #79 was assessed for safe self-administration of medications as required by policy.
F 0584: Facility failed to provide clean washcloths and hand towels in residents' rooms on two units, impacting comfort and hygiene.
F 0585: Facility failed to ensure timely and satisfactory resolution of grievances regarding missing clothing for Resident #16.
F 0600: Facility failed to protect Resident #6 from physical abuse by Resident #11 and did not update care plans or monitor for latent injuries after the incident.
F 0645: Facility failed to perform a required Level II PASRR screening for Resident #24 with schizoaffective disorder.
F 0660: Facility failed to develop and implement an effective discharge plan for Resident #79, who expressed desire to return to the community but lacked active support.
F 0685: Facility failed to offer vision services to Resident #79 who had outdated glasses and was not seen by an eye doctor since admission.
F 0697: Facility failed to ensure effective pain management for Residents #38 and #79 including timely referral to pain clinic, documentation of pain assessments, and administration of PRN medications prior to wound care.
F 0803: Facility failed to follow correct portion sizes and recipe modifications for minced and moist diets, resulting in residents receiving incorrect food textures and amounts.
F 0804: Facility failed to ensure food was palatable, attractive, and served at appropriate temperatures; residents reported poor taste, texture, and appearance of meals.
F 0812: Facility failed to properly date frozen nutritional supplements and thickened liquids, clean the ice machine timely, label and date food in nourishment rooms, properly cool foods, and reheat food to safe temperatures.
F 0814: Facility failed to ensure garbage and refuse were properly disposed of and dumpster lids were closed, resulting in overflowing trash and pest harborage.
F 0838: Facility failed to conduct and document a comprehensive facility-wide assessment including staff competencies, training needs, resources, and risk assessments for day-to-day operations and emergencies.
F 0867: Facility failed to implement an effective quality assurance program to identify and address infection control concerns, contributing to widespread substandard care related to immunizations.
F 0880: Facility failed to ensure tracking, offering, and administration of COVID-19 vaccinations to residents, resulting in multiple residents not being offered or receiving the vaccine.
F 0883: Facility failed to implement policies and procedures for influenza and pneumococcal vaccinations including obtaining physician orders, offering vaccinations, documenting refusals with education, and re-offering annually for multiple residents.
Report Facts
Deficiencies cited: 16
Residents affected by infection control immunization deficiencies: 11
Residents affected by food preference deficiencies: 5
Residents affected by pain management deficiencies: 2
Residents affected by abuse deficiency: 1
Residents affected by grievance deficiency: 1
Residents affected by linen deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported Resident #79 often reported pain and medication changes |
| LPN #4 | Licensed Practical Nurse | Assessed Resident #6 after abuse incident, unaware of grabbing incident |
| LPN #5 | Licensed Practical Nurse | Reported Resident #79 often reported pain |
| CNA #2 | Certified Nursing Assistant | Reported linens stocked but not delivered daily |
| CNA #3 | Certified Nursing Assistant | Reported CNAs only hand trays to residents, dietitian makes meal tickets |
| CNA #4 | Certified Nursing Assistant | Witnessed physical altercation between Resident #6 and Resident #11 |
| Director of Nursing | Director of Nursing | Interviewed regarding medication self-administration and pain management |
| Social Service Director | Social Service Director | Interviewed regarding grievance follow-up and discharge planning |
| Nutrition Services Director | Nutrition Services Director | Interviewed regarding food portion sizes, food quality, and nourishment room issues |
| Medical Director | Medical Director | Interviewed regarding immunizations and pain clinic referral |
| Clinical Nurse Consultant #1 | Clinical Nurse Consultant | Provided multiple policy documents and interviewed on various deficiencies |
| Infection Preventionist | Infection Preventionist | Interviewed regarding immunization and infection control program |
| Corporate Consultant #1 | Corporate Consultant | Interviewed regarding quality assurance and immunization program |
| Unit Manager | Unit Manager | Interviewed regarding medication administration and pain clinic referral |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 19, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of abuse and neglect involving residents, including failure to provide escorts for medical appointments and failure to investigate resident-to-resident physical abuse.
Complaint Details
The complaint involved failure to provide necessary escort and supervision for Resident #1 during a medical appointment, resulting in the resident wandering unsupervised in a medical office near a busy street. Additionally, Resident #3 was physically abused by Resident #4 who pulled her hair, and the facility failed to investigate and intervene timely. The immediate jeopardy was removed after corrective actions were implemented.
Findings
The facility failed to protect residents from abuse and neglect, including failing to provide an escort for Resident #1 during a medical appointment, resulting in immediate jeopardy. Additionally, the facility failed to timely investigate and intervene in a physical abuse incident where Resident #4 pulled hair from Resident #3. The facility implemented corrective actions during the survey.
Deficiencies (2)
F 0600: The facility failed to protect residents from abuse and neglect, including failing to provide an escort for Resident #1 during a medical appointment, which created immediate jeopardy. The facility also failed to protect Resident #3 from physical abuse by Resident #4 and did not investigate or intervene appropriately.
F 0610: The facility failed to timely investigate allegations of physical abuse between Resident #4 and Resident #3 and did not implement safety measures or complete a thorough investigation.
Report Facts
Residents affected: 2
Sample residents: 6
Dates of incidents: 2023-06-12 and 2023-05-22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Operations (RDO) | Interviewed regarding the incidents and corrective actions; involved in lifting immediate jeopardy. | |
| Nursing Home Administrator (NHA) | Former NHA suspended and terminated due to failure to act on incidents; involved in policy and investigation failures. | |
| Social Service Assistant (SSA) | Answered phone during Resident #1 incident; no further action taken. | |
| Central Transport Scheduler | Responsible for scheduling transportation and escorts; failed to ensure Resident #1 had escort. | |
| Certified Nurse Aides (CNA #1 and CNA #2) | Provided care to Resident #1 and observed behaviors of Resident #4. | |
| Registered Nurses (RN #1 and RN #2) | Interviewed about resident behaviors and incidents. | |
| Corporate Consultant (CC) | Involved in investigation and corrective action planning. |
Inspection Report
Routine
Deficiencies: 14
Date: Sep 29, 2022
Visit Reason
Routine state inspection survey to assess compliance with regulatory requirements for University Heights Care Center.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, incomplete baseline care plans, inadequate assistance with activities of daily living, failure to provide appropriate pressure ulcer care, failure to maintain adequate nutrition and hydration, improper medication management, infection control lapses, and failure to ensure palatable and properly served food.
Deficiencies (14)
F558: Facility failed to reasonably accommodate the needs and preferences of residents #440 and #339, including access to call light, walker, and television remote.
F655: Facility failed to fully develop and implement a person-centered baseline care plan for Resident #440 within 48 hours of admission.
F677: Facility failed to provide care and assistance for activities of daily living for Residents #8 and #64, including failure to provide bathing as per care plans.
F679: Facility failed to ensure Resident #440 was offered and assisted with independent leisure activities, including access to television and word searches.
F684: Facility failed to ensure appropriate treatment orders were in place for an open area on Resident #72's right ear and failed to provide treatment as ordered.
F686: Facility failed to provide appropriate pressure ulcer care and prevent new ulcers for Resident #74, including failure to reposition as ordered and inadequate nutritional interventions.
F688: Facility failed to provide appropriate care to maintain or improve range of motion for Residents #44 and #77, including failure to provide braces as per care plans and lack of physician orders for brace application.
F689: Facility failed to ensure Resident #8 and Resident #44 did not have medications and supplements improperly stored in their rooms.
F692: Facility failed to provide adequate nutrition and hydration for Resident #74, including failure to address significant weight loss and failure to provide additional nutritional interventions.
F758: Facility failed to ensure informed consent was obtained for psychotropic medications for Residents #29 and #64 and failed to follow gradual dose reduction recommendations for Resident #36.
F761: Facility failed to ensure all drugs and biologicals were properly stored and labeled, including failure to dispose of loose medications properly, maintain refrigerator temperature, lock medication carts and rooms, and prevent cross-contamination.
F804: Facility failed to ensure food was palatable and served at proper temperature, with multiple resident complaints and test tray observations confirming cold and unappetizing food.
F807: Facility failed to ensure Resident #440 was provided drinks consistent with preferences and sufficient hydration, with fluids often out of reach or unavailable.
F880: Facility failed to implement infection prevention and control practices, including improper cleaning of resident rooms, failure to follow infection control during wound care, and failure to follow infection control during medication administration.
Report Facts
Weight loss: 25.2
Weight loss: 34.4
Medication counts: 44
Refrigerator temperature: 50
MDS BIMS score: 13
MDS BIMS score: 9
MDS BIMS score: 14
MDS BIMS score: 14
MDS BIMS score: 15
MDS BIMS score: 14
MDS BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in medication administration and disposal observation. |
| LPN #1 | Licensed Practical Nurse | Named in medication storage and administration observations. |
| RN #2 | Registered Nurse | Named in medication storage and refrigerator temperature observations. |
| HSK #1 | Housekeeper | Named in resident room cleaning observations. |
| HSK #2 | Housekeeper | Named in resident room cleaning observations. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication, infection control, nutrition, and care plans. |
| DCS | Director of Clinical Services | Interviewed regarding multiple deficiencies including infection control, wound care, and care plans. |
| DM | Dietary Manager | Interviewed regarding food temperature and palatability concerns. |
| IP | Infection Preventionist | Interviewed regarding housekeeping infection control practices. |
| ADON | Assistant Director of Nursing | Named in wound care observations and interviews. |
| LPN #2 | Licensed Practical Nurse | Named in wound care observations. |
| LPN #4 | Licensed Practical Nurse | Named in wound care observations. |
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