Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 University Heights Care Center during CMS and state inspections, most recent first.
The facility did not maintain an effective pest control program, resulting in a persistent cockroach infestation in the kitchen, resident rooms, shower rooms, and common areas. Multiple residents reported ongoing sightings of cockroaches in their living spaces and on dining tables, while staff and pest control records confirmed repeated pest activity and incomplete elimination efforts.
A resident with cognitive impairment and reduced mobility was subjected to physical abuse by a CNA, who continued to provide care and used force despite the resident's repeated requests to stop and expressions of pain. The incident was witnessed by the resident's roommate, who confirmed the resident's distress and the CNA's actions. Facility policies guaranteeing freedom from abuse and the right to dignity were not upheld in this case.
The facility did not conduct thorough investigations into two separate allegations of misappropriation of funds involving two residents, both of whom were cognitively intact and required assistance with ADLs. In both cases, the facility failed to document key investigative steps, such as reviewing banking records, interviewing all relevant staff and family, and following up with law enforcement, resulting in incomplete investigations.
The facility failed to maintain infection control practices during resident care, medication administration, and room cleaning. An LPN provided tube feeding without a gown despite EBP expectations, an RN administered meds and insulin without hand hygiene between glove changes, and a housekeeper changed gloves during room cleaning without hand hygiene. Staff also observed urine collectors and urine hat collectors stored in resident bathrooms without being bagged, dated, or labeled, with brown discoloration noted inside several items.
Failure to Obtain Consent for Psychotropic Medication: A resident with dementia, anxiety, depression, and adjustment disorder received sertraline 100 mg daily on a routine basis, but the EMR did not show consent from the resident or representative before administration. The MAR documented 57 doses across multiple months, and the social worker, DON, and ADON stated consent should have been obtained before the psychoactive medication was given.
A resident with cognitive impairment and physical limitations was observed with unkempt hair, long facial hair, and long fingernails, while records did not show consistent showering, shaving, or nail care and the resident said he had not received these services in a long time. Another cognitively intact resident whose communication preference was Spanish had difficulty communicating with staff, was not offered translation support during medication administration, and was observed sitting alone while activities were conducted in English despite a care plan calling for Spanish-speaking support or a translator.
A resident with esophageal cancer, cognitive impairment, and poor meal intake did not consistently receive dining assistance. Staff repeatedly delivered lunch trays and left them covered on a bedside table without setting them up or encouraging intake, and an RN also failed to ensure the resident was able to eat. Records showed the resident’s eating ability ranged from independent to dependent, but the care plan did not include eating assistance interventions.
Failure to provide personalized activities in residents’ preferred language. Two cognitively intact residents with documented interests in music, group activities, going outdoors, and religious services primarily spoke Spanish, but activities were conducted in English and calendars were not provided in a usable Spanish format. Surveyors observed staff not inviting one resident to bingo, coffee social, rosary, or church service activities, and the other resident said he stopped attending bingo because he could not understand it in English.
A resident with a stage 4 sacral pressure injury, paraplegia, and dependence for bed mobility did not receive consistent turning, repositioning, or proper air mattress settings. Staff were observed leaving the resident lying flat on his back for hours while the mattress stayed on the 600 lb to 1000 lb setting instead of the ordered less-than-250-lb setting, despite care plan interventions and physician orders to encourage repositioning and monitor mattress function.
Improper Suprapubic Catheter Positioning: A resident with MS, neurogenic bladder, and a suprapubic catheter was observed sitting in a wheelchair with the catheter bag attached to the back of the chair at about mid-back level and the tubing coiled on the thigh in loops. The resident’s care plan and orders required the bag and tubing to be positioned below the bladder and kept unobstructed, secured, and free of kinks, and the DON, IP, and ADON all confirmed that the observed placement was not appropriate.
A resident with PTSD, cognitive impairment, and multiple psychiatric diagnoses did not have a trauma behavior assessment or a PTSD care plan identifying triggers and interventions in the EMR. The MDS noted PTSD, but record review found no trauma assessment or individualized care plan until during the survey, and the DON, ADON, and social worker quality mentor agreed these items should have been completed earlier.
A resident with type 2 DM and neuropathy received Lantus insulin from an RN who sanitized the pen, attached the needle, dialed the ordered dose, and administered it without properly priming the pen first. The manufacturer’s instructions required a safety test before each injection to ensure an accurate dose, and the DON confirmed insulin pens should be primed with two units before the dose is given.
Medication Storage and Labeling Deficiencies: Open inhalers and eye drops in two med carts were found without open dates, and multiple expired medications remained in the carts, including Biofreeze, duloxetine, hydralazine, guaifenesin, calcium, and furosemide. An LPN stated he or she did not know the items needed open dates, and the DON said inhalers and eye drops should be dated when opened.
A resident receiving hospice care had diagnoses including cancer, PE, cognitive impairment, depression, bipolar disorder, and adult failure to thrive. The facility failed to ensure hospice notes and visit documentation were readily accessible in the EMR for staff to coordinate care; instead, records were kept in a hospice binder with missing or limited entries. Staff interviews showed reliance on hospice communication, but the DON and NHA were unaware of missing documentation, and surveyors found the hospice records were not available to nursing staff during the survey.
Three residents were not protected from physical abuse by peers, including two incidents where a resident with schizoaffective disorder and Alzheimer's physically assaulted others in the hallway, and another incident where a resident with mood disorder and dementia struck a peer in the dining room. Staff did not consistently supervise or intervene, and care plans were not updated after repeated incidents, allowing abuse to occur.
A resident with dementia and schizophrenia, identified as an elopement risk and equipped with a wander guard, was able to leave the facility unsupervised through a back door and fence. Staff were unable to locate the resident after the alarm was triggered, and the facility did not conduct a thorough investigation or report the incident to the State Agency.
A resident with dementia and a history of physical aggression did not receive person-centered interventions as outlined in her care plan, such as staff supervision and hallway positioning, resulting in multiple incidents of physical aggression toward others. Staff interviews and observations confirmed that interventions were not consistently implemented, and the resident was often left unsupervised in common areas.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent cockroach infestation throughout multiple areas, including the kitchen, resident dining room, resident rooms, shower rooms, and hallways. Observations revealed unsanitary conditions such as food spills and debris in the kitchen, as well as live and dead cockroaches in various locations, including common areas and resident shower rooms. Glue-based traps were found heavily populated with cockroaches, indicating ongoing pest activity. Multiple residents reported frequent sightings of cockroaches in their rooms, on walls, in beds, and even on dining tables during meals. One resident stated that the infestation had been ongoing for about a year and had not been eliminated, despite some rooms being closed for treatment. Residents expressed dissatisfaction with the facility's efforts to address the problem, noting only minor improvements and continued widespread presence of cockroaches. Pest control records documented repeated findings of cockroach and rodent activity during several service visits, with treatments focused on the kitchen and select resident rooms. Staff interviews confirmed the presence of cockroaches in resident rooms, shower rooms, and occasionally in the kitchen. The maintenance director acknowledged that the infestation worsened several months prior, prompting a change in pest control providers and targeted treatments, but admitted that cockroaches were still present in the building.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a certified nurse aide (CNA). The incident involved a resident with multiple contractures, reduced mobility, and moderate cognitive impairment, who was dependent on staff for activities of daily living. During an episode of care, the resident requested that the CNA stop providing care, expressing pain and distress, but the CNA continued despite these requests. The resident reported being pushed hard against the wall and having his knees pushed into the window, resulting in him yelling out for the CNA to stop. A roommate who was present during the incident confirmed hearing the resident yell and ask the CNA to stop, but observed that the CNA continued with the care. The roommate also reported hearing a loud scream, which prompted a nurse to enter the room. The CNA involved provided a written statement acknowledging that the resident asked her to stop, but she continued with the care, stating she was almost done. Staff interviews indicated that the resident was generally pleasant and did not typically refuse care, though he could be hesitant and nervous during assistance. The facility's policies guarantee residents the right to be free from abuse, neglect, and corporal punishment, and to be treated with dignity and respect. Despite these policies, the actions of the CNA in this incident resulted in a failure to uphold these rights for the resident involved.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to ensure a thorough investigation of alleged misappropriation of funds for two residents. In the first case, a resident reported that two unidentified individuals entered her room and took her debit card under the pretense of purchasing snacks, but never returned. The facility's investigation did not document efforts to obtain the resident's banking information or verify if unauthorized charges occurred. Additionally, the investigation did not include interviews with staff or family members, nor did it follow up with law enforcement regarding the status of the case. The investigation was closed after the resident was discharged, without determining if other residents were at risk. In the second case, another resident reported unauthorized transactions from his bank account, including significant online money transfers and food delivery charges. The facility's investigation did not document efforts to identify the recipients of these transactions or review relevant banking records. Although the incident was reported to the police, there was no documentation of follow-up with law enforcement. The investigation also failed to include interviews with staff members who may have had relevant information and did not obtain statements from the business office manager, who managed the resident's funds. Both residents involved were cognitively intact according to their assessments, and both required assistance with activities of daily living. The facility's documentation was incomplete, lacking details of investigative steps taken, such as attempts to contact family members, review of financial records, and interviews with all relevant parties. The investigations were closed without sufficient evidence to substantiate or unsubstantiated the allegations, and without ensuring that all investigative avenues were pursued.
Infection Control Lapses During Resident Care, Medication Administration, Room Cleaning, and Urine Collector Storage
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. One deficiency involved enhanced barrier precautions (EBP): an LPN provided tube feeding through a resident’s feeding tube, washed hands, and donned clean gloves, but did not wear a gown during the tube feeding procedure. The LPN later stated she should have worn a gown during administration of the tube feeding formula. The facility also failed to ensure hand hygiene was completed during medication administration. An RN prepared and administered medications to a resident, including checking blood glucose and giving an insulin injection. After removing gloves and leaving the room, the RN returned, donned clean gloves, and sanitized the blood glucose machine. She then re-entered the room, donned clean gloves again, and administered pills and another insulin injection without performing hand hygiene between glove changes. Hand hygiene was also not completed during cleaning of a resident room. A housekeeper cleaned a resident room, removed trash, sprayed and wiped surfaces, and changed gloves during the process, but did not perform hand hygiene after removing gloves before putting on clean gloves again. In addition, urine collectors were observed stored in resident bathrooms without being bagged, dated, or labeled. Multiple urine collectors and urine hat collectors were seen sitting on toilet tank lids or shelves, some with brown discoloration inside the plastic. The DON confirmed the collectors were not dated, labeled, or bagged, and staff interviews reflected differing expectations about labeling and storage.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure consent was obtained before administering a psychotropic medication to Resident #16. The resident was admitted with diagnoses including dementia with anxiety, depression, and adjustment disorder with mixed disturbance of emotions and conduct. The 6/19/25 MDS showed the resident was moderately cognitively impaired with a BIMS score of 10 out of 15 and that an antidepressant/antipsychotic medication was administered on a routine basis only. Record review showed the resident had care plans for depression and for use of an anti-psychotic medication related to symptoms/behaviors associated with depression. A physician order dated 5/9/25 directed staff to administer sertraline HCl 100 mg daily for depression, and the MARs for June, July, and August 2025 showed the resident received the medication as ordered for a total of 57 doses. Review of the EMR did not reveal documentation that the resident or the resident's representative provided consent before the sertraline was administered. During interviews, the social worker quality mentor, DON, and ADON each stated that consent should be obtained before administration of a psychoactive medication. They also stated that the consent for sertraline was completed on 8/6/25 during the survey, after the medication had already been administered on the MARs for June, July, and August 2025.
Failure to Provide ADL Assistance and Language Communication Support
Penalty
Summary
The facility failed to ensure that a resident with chronic obstructive pulmonary disease, depressive disorder, a history of traumatic brain injury, anxiety disorder, wheelchair dependence, and a contracture of the right wrist and hand consistently received assistance with personal hygiene. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15, and he required moderate assistance with personal hygiene and maximal assistance with showers. The care plan identified an ADL self-care performance deficit and included interventions for checking nail length and trimming and cleaning on bath day and as needed, but it did not include interventions for shower refusals or shaving. During observations, the resident was seen in bed with unkempt, uncombed hair, long and unshaped facial hair, and fingernails about one and a half inches long. On later observations, his hair and beard remained long and uncombed, his clothing was unchanged, his shirt had food debris on it, and his fingernails remained long; one index fingernail was missing. The resident stated he had not had a shower in a long time, wanted his nails cut and trimmed, said he had bumped and lost a fingernail, and wanted to be shaved and get a haircut. He said he needed assistance with personal hygiene and had not received shaving or a haircut for a long time. Record review did not show documentation that the resident had received a shower, shaving, or fingernail care, and requested shower, fingernail care, and shaving records for the prior six months were not provided during the survey. Staff interviews indicated CNA staff were responsible for showers and personal hygiene care, and that refusals should be offered again, escalated to the nurse, and documented. The DON stated shower refusals were to be documented on the shower sheet and in progress notes, but she did not know why the records were not showing for the resident. The facility also failed to provide language communication tools for a resident whose communication preference was Spanish. The resident was cognitively intact with a BIMS score of 13 out of 15 and required moderate assistance with personal hygiene and supervision or touch assistance with bathing, toileting, and lower body dressing. Her care plan stated she spoke Spanish and required Spanish-speaking staff, family, a translation line, or an online translator when communicating with her. The resident said it had been difficult to communicate with staff and attend activities because staff did not understand her, and she stopped attending bingo, religious groups, and social interactions. She said staff had never used a communication line or device to assist her. Observations showed an LPN administered medication while the LPN and resident could not understand each other, and the LPN left without attempting to use the translator line. Another observation showed a CNA entered the resident’s room and did not speak to her while bingo was occurring in the main dining room. Staff interviews confirmed the resident only spoke Spanish, the facility had a translation line, and activities were conducted in English.
Failure to Assist Resident With Meals
Penalty
Summary
The facility failed to provide necessary assistance with dining for one resident who had diagnoses including esophageal cancer, pulmonary embolism, cognitive impairment, depression, bipolar disorder, and adult failure to thrive. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 11, and the record also showed poor meal intake and repeated notes that staff were to encourage food and fluids as the resident was able and willing to accept. The ADL care plan identified an ADL self-care performance deficit, but it did not include interventions to assist with eating, even though hospice care planning noted the resident needed ADL support adjusted to his changing abilities. During observation, staff repeatedly delivered lunch trays to the resident’s room and left them covered on a bedside table several feet from the bed without setting them up or encouraging the resident to eat. On one occasion, CNA #6 brought the lunch tray and left it covered while the resident remained lying in bed awake; RN #4 entered later to deliver medications but did not encourage the resident to eat or ensure the tray was within reach. The next day, CNA #7 again left the lunch tray covered on the bedside table, and the resident was observed lying in bed asleep with the tray still untouched. Another observation showed staff interacting with the roommate while not speaking with the resident. Record review showed the resident’s eating ability fluctuated over the lookback period, with entries ranging from independent eating to setup assistance, partial assistance, substantial assistance, and dependence on staff. Staff interviews reflected that the resident often refused meals and that his ability to eat had declined, with the DON stating the resident needed setup assistance for meals, including uncovering the tray and opening containers. Despite this, the observations documented that staff did not consistently provide the meal setup and encouragement described in the resident’s care needs and progress notes.
Failure to Provide Personalized Activities in Residents’ Preferred Language
Penalty
Summary
The facility failed to provide two residents with an ongoing, personalized activity program designed to meet their needs and interests and promote physical, medical, and psychosocial well-being. One resident was cognitively intact, had diagnoses including type 2 diabetes mellitus, major depressive disorder, chronic kidney disease, unsteadiness on feet, reduced mobility, and a history of falling, and her documented preferences included music, animals, news, group activities, and going outside. Another resident was cognitively intact, had diagnoses including schizoaffective disorder, bipolar type, urinary retention, and atrial fibrillation, and his documented preferences included music, animals, group activities, favorite activities, going outside, and religious services. The first resident spoke Spanish and told surveyors she liked bingo when it was conducted in her native language, but she stopped attending because bingo was conducted in English and she did not understand it. She said she would be interested in attending if bingo were offered in Spanish. During interview, an activity calendar printed in Spanish was observed posted high on the wall in her room, and she said she was unable to read it. Observations showed she was left in her room or bed while bingo was occurring in the dining room, and staff did not offer her assistance to attend the activity or provide the language line for translation. Staff interviews reflected that multiple staff members knew she only spoke Spanish and that all activities were held in English, with one staff member stating the language barrier likely explained her refusal to participate. The second resident primarily spoke Spanish and said there were no activities offered in Spanish. He stated he would like to attend more activities if they were offered in Spanish and said the activity calendar in his room was printed in English. Observations showed that during coffee social, rosary, and church service activities, staff did not go into his room to invite him to participate. His activity assessment and care plan documented preferences for group, independent, outdoor, music, religious, and other activities, but the care plan did not document that he spoke primarily Spanish or preferred activities in Spanish. Staff interviews confirmed he primarily spoke Spanish, that he knew little English, and that the facility did not currently offer activities in languages other than English.
Failure to Consistently Reposition and Maintain Mattress Settings for a Resident With a Stage 4 Sacral Pressure Injury
Penalty
Summary
The facility failed to ensure pressure injury care was consistently provided for a resident admitted with a stage 4 sacral pressure ulcer, multiple sclerosis, paraplegia, and significant dependence on staff for bed mobility. The resident’s care plan and physician orders included use of an air mattress set to less than 250 lbs firmness and encouragement to turn and reposition as tolerated. The resident was cognitively intact and was documented as dependent or requiring substantial assistance for rolling and bed mobility, with no documented refusals for repositioning in the TARs or CNA task records. During direct observation, the resident remained lying flat on his back for nearly five hours while staff entered and exited the room for meals, call lights, wound care, and other tasks. Staff assisted with small shifts in bed at times, but the resident continued to lie on his back and was not encouraged to reposition off his back. The resident’s air mattress remained set to the 600 lb to 1000 lb setting throughout the observation period, including times when wound care was not being provided. On another observation day, the resident was again found lying on his back with the mattress still set to the higher setting. Record review showed the resident’s stage 4 sacral wound had been evaluated multiple times by the wound care physician, with notes documenting improvement at times and worsening at other times. One wound note documented that nursing staff reported the resident refused to turn and reposition despite encouragement, but the facility records reviewed did not show any refusals. Interviews with staff indicated the resident needed help to turn and that staff were expected to encourage repositioning whenever they were in the room, yet observations showed this was not consistently done. The DON and ADON acknowledged the mattress should normally be set to less than 250 lbs and that staff should offer repositioning throughout the day, but the observed care did not match those expectations.
Improper Suprapubic Catheter Positioning
Penalty
Summary
The facility failed to ensure a resident with a suprapubic catheter received appropriate catheter care and services according to professional standards. Resident #2, who had multiple sclerosis, weakness, neuromuscular dysfunction of the bladder, and a neurogenic bladder, had an indwelling suprapubic catheter ordered with staff directed to monitor placement and function, provide catheter care each shift, and ensure the catheter was unobstructed, secured, and draining appropriately. The resident’s care plan also directed staff to position the catheter bag and tubing below the level of the bladder and to check the tubing for kinks with cares and each shift. During observations, the resident was sitting in a wheelchair with the catheter bag attached to the back of the wheelchair at approximately mid-back level, above the bladder, and the catheter tubing resting on the left thigh in two loops. This same positioning was observed multiple times, and the tubing contained clear fluid, with yellow sediment noted during one observation. The DON, IP, and ADON all stated the catheter bag and tubing should be positioned below the bladder and free of coils and kinks, but the observed placement did not reflect that care.
Failure to Assess and Care Plan PTSD-Related Trauma Triggers
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of PTSD received trauma-informed and culturally competent care in accordance with professional standards of practice. The report states that the facility did not complete an assessment to identify potential trauma behaviors for Resident #82 and did not develop a care plan for the resident’s PTSD that included possible escalating triggers and appropriate interventions. Resident #82 was admitted and readmitted to the facility and had diagnoses that included Parkinsonism, schizoaffective disorder bipolar type, depression, moderate intellectual disability, and PTSD. The 6/24/25 MDS assessment showed the resident was moderately cognitively impaired with a BIMS score of 10 out of 15 and indicated no behaviors, while also identifying PTSD. A psychological follow-up note dated 7/2/25 stated the resident continued to have severe cognitive deficits with behavioral disturbances secondary to dementia and listed dementia with behavioral disturbances, schizoaffective disorder, and PTSD. Record review failed to reveal an assessment for trauma behaviors or a care plan for PTSD that identified triggers and interventions. During interviews, the social worker quality mentor, DON, and ADON all agreed that the resident’s PTSD diagnosis should have prompted a trauma assessment and a care plan with triggers and interventions, and they stated these should have been completed within the first seven days after admission. The social worker quality mentor also stated the resident trauma behavior assessment and PTSD care plan were completed during the survey.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure that a resident was free from a significant medication error when RN #2 administered Lantus insulin without properly priming the insulin pen before giving the dose. Resident #42 had diagnoses including type 2 diabetes mellitus with neuropathy and was cognitively intact with a BIMS score of 12 out of 15. The resident had physician orders for insulin glargine 24 units subcutaneously with breakfast and 20 units at bedtime. During the morning medication pass, RN #2 checked the resident’s blood glucose at 155 mg/dl, administered Humalog insulin, and then prepared the Lantus pen for the scheduled dose. RN #2 sanitized the rubber stopper, attached the needle, and dialed the pen to 24 units, but did not prime the pen before administering the insulin into the resident’s lower abdomen. The manufacturer’s instructions for the Lantus Solostar pen state that a safety test must be performed before each injection to ensure an accurate dose and remove air bubbles, and that failure to do so could result in an underdose or no insulin at all. Although RN #2 later stated she had primed the pen with two units before attaching the needle, the observation documented that the pen was not primed prior to drawing up and administering the dose. The DON stated that all insulin pens should be primed with two units of insulin, with the needle in place, before the dose is drawn up.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications in two medication carts and one medication storage room were properly labeled and stored. During observation of the South back medication cart with an LPN, several open inhalers were found with resident names and dosage information but no open date, including Trelegy 200 mcg/62.5 mcg/25 mcg, Trelegy 100 mcg/62.5 mcg/25 mcg, Spiriva 2.5 mcg, Airsupra 90 mcg/90 mcg, and Albuterol 90 mcg. The LPN stated she was not aware the inhalers needed to be labeled with an open date. During observation of the North front medication cart with another LPN, additional open medications were found without open dates, including Albuterol inhaler 90 mcg, Dorzolamide-timolol eye drops, Polymyxin B sulfate and trimethoprim eye drops, Timolol maleate eye drops, and Simbrinza eye drops. The LPN stated he did not know the inhalers or prescription eye drops should have been labeled with an open date. The DON later stated eye drops should be labeled with an open date because they are generally good for 30 days, and inhalers should also be labeled with an open date. Expired medications were also found in the medication carts. In the South back cart, an open bottle of Biofreeze gel 4% and a partially used duloxetine medication card were expired. In the North front cart, an open bottle of Biofreeze gel 4%, an open bottle of ferrous sulfate 325 mg with no expiration date verified, a partially used hydralazine 25 mg card, an open bottle of guaifenesin 600 mg, an open bottle of calcium 600 mg, and a partially used furosemide 40 mg card were all expired. One LPN stated expired medication should be discarded, and another said it was not best practice to keep expired medications in the carts.
Hospice documentation was not readily accessible to facility staff
Penalty
Summary
The facility failed to ensure hospice services met professional standards and principles for one resident receiving hospice care. The resident had diagnoses including pulmonary embolism, esophageal cancer, cognitive impairment, depression, bipolar disorder, and adult failure to thrive, and was documented as moderately cognitively impaired with a BIMS score of 11 out of 15. The resident’s hospice care plan called for hospice nurse visits one to two times per week, hospice CNA visits twice weekly, and monthly or as-needed visits from the hospice chaplain and social worker. Surveyors found that hospice documentation was not readily accessible to facility staff in the resident’s EMR and was instead kept in a hospice binder. The binder contained limited hospice notes, and the EMR did not contain hospice provider documentation of hospice services and/or visits. During observation, a hospice CNA note documented a visit during a time when no staff were observed entering the resident’s room. Facility staff interviews reflected that CNAs, an RN, the DON, and the NHA all relied on hospice staff to communicate visits and care, but the DON also acknowledged missing hospice visit documentation in the binder. The NHA stated he or the DON oversaw hospice visits, but was not aware of missing hospice CNA or nurse documentation. Additional hospice records were later obtained from the hospice provider during the survey process and showed more frequent nurse and CNA visits than were available to nursing staff at the time of the survey. However, those records were not readily available to nursing staff during the survey, and the additional information still did not show documented CNA visits on several dates listed in the report. The deficiency was based on the facility’s failure to ensure hospice agency notes regarding the resident’s care were easily accessible to staff to support coordination of care with the hospice agency.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect three residents from physical abuse by other residents, as required by its abuse prevention policy. In two separate incidents, one resident with schizoaffective disorder, anxiety, and Alzheimer's disease physically assaulted two other residents in the hallway. The assailant had a documented history of paranoia, short temper, and previous physical aggression, with care plans noting the need for interventions such as one-to-one conversations, emotional support, and staff monitoring. Despite these interventions, the care plan was not updated after the second incident of physical abuse, and staff interviews revealed that staff did not consistently provide supervision or intervene to prevent altercations, especially when the resident was having a 'bad day.' Staff reported giving the resident space rather than actively preventing contact with other residents, even though the resident was known to become physically aggressive if her personal space was invaded. In a separate incident, another resident with mood disorder, dementia, and a history of traumatic brain injury physically assaulted a peer in the dining room. The aggressor approached the other resident, yelled, and then struck him, causing the victim to tip over backwards in his wheelchair. Staff and witness interviews confirmed that the aggressor initiated the altercation, and the incident was substantiated by video review. The care plan for the aggressor included interventions for anger, anxiety, and poor impulse control, but the incident still occurred. The victim, who had spina bifida and Wernicke's encephalopathy, was known for frequent outbursts and yelling but had no history of physical aggression. In both cases, the facility's failure to provide adequate supervision, update care plans, and implement effective interventions allowed physical abuse to occur between residents. Staff interviews indicated a lack of consistent monitoring and intervention, particularly for residents with known behavioral risks. The incidents were witnessed by staff, and in each case, the facility's response did not prevent the recurrence of resident-to-resident abuse.
Failure to Prevent and Investigate Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with a known history of wandering and elopement risk. The resident, under the age of 65, had diagnoses of dementia and schizophrenia, and was assessed as having moderate cognitive impairment. The care plan identified the resident as an elopement risk, with interventions including a wander guard, structured activities, and specific redirection strategies. Despite these measures, the resident was able to leave the facility unsupervised through the back door and a wood fence in the early morning hours. Staff interviews and record reviews revealed that the resident was a supervised smoker and had a history of attempting to remove his wander guard. On the day of the incident, the wander guard alarm was triggered, but staff were unable to locate the resident after searching the area. The alarm response procedures were unclear, and staff could not specify how quickly they responded or what actions were taken immediately after the alarm sounded. The resident was eventually found and returned to the facility without injury, but the circumstances of his departure and the staff's response indicated a lapse in supervision and monitoring. Additionally, the facility did not conduct a thorough investigation of the elopement incident, nor did it report the event to the State Agency as required. The nursing home administrator confirmed that no investigation report was completed for the incident. This lack of follow-up and documentation further demonstrated a failure to ensure resident safety and compliance with facility policies regarding elopement and accident prevention.
Failure to Implement Person-Centered Interventions for Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, specifically by not implementing person-centered interventions to prevent physically aggressive behaviors toward other residents. The resident, a 71-year-old with diagnoses including schizoaffective disorder, anxiety disorder, and Alzheimer's disease, had a documented history of moderate cognitive impairment and required assistance with daily activities. Her care plan included interventions such as encouraging her to travel on one side of the hallway, assigning a one-to-one caregiver for emotional support, and having staff walk between her and other residents to prevent altercations. Despite these documented interventions, direct observations revealed that staff did not encourage the resident to travel on one side of the hallway or provide supervision as she moved throughout the facility. The resident was observed self-propelling her wheelchair in hallways and common areas without staff intervening or positioning themselves between her and other residents, as outlined in her care plan. Multiple incidents were documented in which the resident became physically aggressive, including hitting or slapping other residents and attempting to scratch staff, often triggered by perceived invasions of her personal space. Interviews with CNAs and nursing staff confirmed that staff typically gave the resident space when she was upset and did not walk with her or intervene between her and other residents, citing concerns for their own safety. The DON and NHA acknowledged that staff were expected to implement the care plan interventions, including monitoring the resident and positioning themselves to prevent aggressive incidents, but these measures were not consistently carried out. As a result, the facility did not ensure the resident received the necessary person-centered care to maintain her highest practicable well-being and prevent harm to others.
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 499 citations issued within 25 miles in the last 12 months — including the 7 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) |
|---|---|---|---|---|
| Aviva At Fitzsimons | 1.7 mi | ★★★★★ | 1 | 0 |
| Veterans Community Living Center At Fitzsimons | 1.7 mi | ★★★★★ | 0 | 0 |
| Highland Park Rehabilitation & Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Lowry Hills Care And Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
| Garden Terrace Alzheimer's Center Of Excellence | 2.7 mi | ★★★★★ | 2 | 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.