Above 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 Highland Park Rehabilitation & Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk of resident accidents.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Several residents reported that the menu was too repetitive, with frequent servings of chicken, pork, and mixed vegetables. Review of four weeks of menus confirmed repeated use of the same food items, and staff interviews revealed challenges with food deliveries and lack of clear alternate menu options, resulting in limited variety and unmet resident preferences.
The facility did not conduct a thorough investigation after an incident where one resident threw coffee at another during a dining activity. Despite staff statements indicating the coffee was directed at the other resident, the investigation did not include interviews with all key witnesses, such as an LPN and a pulmonary program coordinator who observed the event. The investigation also failed to document all relevant details and did not follow the facility's abuse policy, resulting in an incomplete assessment of the incident involving two cognitively impaired residents.
The facility failed to provide proper respiratory care for three residents by not adhering to cleaning and storage protocols for CPAP, BiPAP, and nebulizer equipment. Residents reported that their equipment was not cleaned as per physician's orders, and observations confirmed improper storage practices. Staff interviews indicated a lack of consistent adherence to cleaning responsibilities.
A housekeeper in an LTC facility failed to follow proper infection control practices, including neglecting hand hygiene between tasks, not disinfecting high-touch areas, and using the same cleaning cloth for different areas. The housekeeper also did not clean from cleanest to dirtiest areas, as per facility policy, leading to potential infection risks.
The facility did not post staffing information, including hours worked by licensed and unlicensed staff, in a prominent place accessible to residents and visitors. Observations over three days confirmed the absence of postings, and interviews with the RCC, DON, and NHA revealed a lack of awareness and responsibility for ensuring the information was displayed.
The facility failed to maintain sanitary conditions in the kitchen by not ensuring staff wore hair restraints while handling food and not covering fluorescent ceiling lights above food preparation areas. Observations and staff interviews revealed a lack of awareness and availability of hair restraints, and uncovered light fixtures, posing potential contamination risks.
The facility failed to maintain an effective pest control program, resulting in bugs being found in hallway ceiling light fixtures and a resident's room. Despite reports from staff and residents, no immediate action was taken to address the issue, leading to ongoing concerns.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the failure to promptly inform all required parties when significant events impacting the resident occurred, as required by regulation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Varied and Well-Balanced Diet
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, and well-balanced diet that met their daily nutritional and special dietary needs, as well as their preferences. Multiple residents reported that the menu was too repetitive, with frequent servings of chicken, pork, and various vegetable blends. Residents expressed dissatisfaction with the lack of variety, particularly in the vegetables offered, noting that mixed vegetables and similar blends appeared on the menu multiple times each week. A review of four weeks of facility menus confirmed the repetition of certain food items, especially chicken, pork, potatoes, rice, and various vegetable blends. Staff interviews revealed that the dietary manager had identified menu variety and food quality as areas needing improvement. The dietary manager also reported challenges with food deliveries, which sometimes prevented her from providing a greater variety of vegetables. Additionally, while residents could request alternate menu items, these options were not clearly listed on the alternate menu, and there was confusion among staff regarding how residents were informed about specific vegetables being served.
Failure to Thoroughly Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving two residents. According to the facility's policy, an immediate and comprehensive investigation is required when abuse is suspected or reported, including identifying and interviewing all involved parties and witnesses, and documenting the process. In this incident, one resident with a history of combative behavior threw a cup of coffee in the direction of another resident during a dining room activity. The resident who threw the coffee was immediately removed and placed under one-to-one supervision, and both residents were assessed for harm. The investigation conducted by the facility did not include all relevant witness interviews or documentation. Specifically, the investigation failed to document that the coffee was thrown directly at the other resident, despite statements from staff indicating this occurred. Key witnesses, including an LPN and the pulmonary program coordinator who observed the incident, were not interviewed or their statements were not included in the investigation file. Additionally, staff who were interviewed as part of the investigation were not present during the incident, and the investigation did not capture all available information about the event. The residents involved had significant cognitive impairments and required supervision for activities of daily living. The resident who was the alleged victim was monitored after the incident and showed no signs of pain or discomfort. The facility's documentation and investigation process did not align with its own abuse policy, as it did not ensure all relevant staff were interviewed or that all evidence was collected and documented. The nursing home administrator acknowledged that the investigation was incomplete and that the incident was not clearly identified as abuse versus a behavioral issue.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required the use of CPAP, BiPAP, and nebulizer equipment. The facility did not adhere to its own policies and procedures, which were aligned with CDC guidelines and manufacturer's recommendations, to prevent the spread of infection. Specifically, the facility did not follow physician's orders for cleaning, sanitizing, and storing the respiratory equipment for the residents involved. Resident #19, who had chronic obstructive pulmonary disease and obstructive sleep apnea, was observed multiple times with her CPAP mask improperly stored on her dresser or on the floor, contrary to the facility's policy of storing it in a plastic bag or enclosed case. The resident reported that the staff never cleaned her CPAP machine or mask, despite physician's orders for daily cleaning. Similarly, Resident #54, who had chronic respiratory failure and obstructive sleep apnea, had her BiPAP mask improperly stored and reported that it had not been cleaned since her admission. The care plan for Resident #54 failed to include instructions for cleaning and storing the BiPAP equipment. Resident #25, who had chronic obstructive pulmonary disease, was observed with her nebulizer equipment not properly rinsed and stored after use. The resident stated that the staff sometimes placed the nebulizer cup and mouthpiece in a bag, but often left it on the nightstand without rinsing. Staff interviews revealed that the responsibility for cleaning and storing the respiratory equipment was not consistently followed, with nurses failing to adhere to the physician's orders for cleaning and storage. The DON confirmed that the equipment should be cleaned and stored as per the physician's orders to prevent infections.
Inadequate Infection Control Practices by Housekeeper
Penalty
Summary
The facility failed to maintain an effective infection control program on one of its units, as evidenced by the actions of a housekeeper, HSK #1, who did not adhere to proper cleaning and disinfection protocols. Observations revealed that HSK #1 did not perform hand hygiene before putting on gloves and failed to change gloves or sanitize hands between different cleaning tasks. This included moving between different areas of a resident's room and between different rooms without proper hand hygiene, which is critical to preventing the spread of infection. HSK #1 also did not follow the correct order of cleaning from cleanest to dirtiest areas, as recommended by both the facility's policy and professional guidelines. For instance, HSK #1 placed a dirty toilet bowl bucket on a resident's bedside table and used the same cleaning cloth for different sides of a double occupancy room. Additionally, high-touch areas such as call lights, door knobs, and TV remotes were not disinfected, and the toilet was not cleaned with the appropriate disinfectant. Interviews with HSK #1 and the housekeeping and laundry manager (HLM) revealed a lack of understanding and adherence to proper infection control practices. HSK #1 admitted to not realizing the importance of changing gloves and performing hand hygiene between tasks. The HLM confirmed that housekeepers were trained to clean from cleanest to dirtiest areas and to perform hand hygiene between glove changes, but there was no documentation of audits or on-the-spot education provided to staff. The infection preventionist (IP) also emphasized the importance of cleaning high-touch areas daily and performing hand hygiene to prevent infection spread.
Failure to Post Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information, including the total number of actual hours worked by licensed and unlicensed staff directly responsible for resident care per shift, was posted in a prominent place readily accessible to residents and visitors. Observations on three consecutive days revealed that there were no staff postings, including hours worked, visible in the facility. Interviews with the regional clinical coordinator, the director of nursing, and the nursing home administrator confirmed that the staffing information had not been posted, and there was uncertainty about whose responsibility it was to ensure the postings were made.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility did not ensure that hair restraints were worn by staff while preparing, handling, cooking, and serving food for the residents. Observations revealed that the dietary manager, dietary cooks, and other staff members were not wearing hair restraints at various times while handling food. Interviews with the dietary manager and other staff indicated a lack of awareness and availability of hair restraints, leading to potential contamination of food. Additionally, the facility did not ensure that fluorescent ceiling lights above areas where food was prepared, cooked, and served were covered by light shades. Observations showed that three out of four light fixtures in the main kitchen did not have protective light shades. Interviews with the dietary manager and environmental service director revealed that they were aware of the regulation but had not taken steps to ensure the lights were covered, posing a risk of glass contamination in the food if a light bulb were to break. The facility's failure to adhere to professional standards and its own policies regarding hair restraints and light coverings in the kitchen resulted in unsanitary conditions that could potentially compromise the safety and quality of the food served to residents. Staff interviews highlighted a lack of proper oversight and timely action to address these deficiencies, contributing to the observed non-compliance with health regulations.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to ensure an effective pest control program, resulting in bugs being found in hallway ceiling light fixtures and a resident's room. Specifically, bugs were observed in the light fixtures on the 200 and 500 hallways, and approximately 20 dead bugs were found on a resident's window ledge, with more bugs in the window track. The environmental service director (ESD) was unaware of the issue, and the nursing home administrator (NHA) indicated that it was the floor technician's (FT) responsibility to clean the light fixtures. The FT had reported the issue to the assistant environmental service director (AESD), who in turn informed the ESD, but no action was taken to resolve the problem. Resident #4 had an ongoing bug problem in his room, which he reported during a care conference. Despite the issue being brought to the attention of the social services staff and the facility management team, no immediate action was taken to address the problem. The resident's family member also observed the bugs and expressed hope that the facility would resolve the issue. The social service director (SSD) found a grievance form about the bug problem and discussed it in a morning meeting, but the issue remained unresolved hours later. Interviews with staff revealed a lack of communication and follow-up regarding the pest control issue. The AESD mentioned that a pest control company had visited the facility and promised to order bug traps, but the traps never arrived, and no follow-up was conducted. The NHA requested a new pest control company to address the issue, but the problem persisted at the time of the report. The facility's failure to maintain an effective pest control program led to the presence of bugs in the light fixtures and a resident's room, causing concern among residents and staff.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 516 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lowry Hills Care And Rehabilitation | 0.2 mi | ★★★★★ | 0 | 0 |
| Center At Lowry, Llc | 1.1 mi | ★★★★★ | 11 | 0 |
| Veterans Community Living Center At Fitzsimons | 2.2 mi | ★★★★★ | 0 | 0 |
| Hilltop Park Post Acute | 2.3 mi | ★★★★★ | 1 | 0 |
| Berkley Manor Care Center | 2.5 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.