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 University Park Care Center during CMS and state inspections, most recent first.
A facility failed to thoroughly investigate an alleged physical abuse incident involving a resident and his spouse. The investigation lacked documentation of the spouse interview timing and questions, omitted a statement from the RD who witnessed the event, did not document restricting the spouse’s facility access during the investigation, and did not record when education was provided. Staff interview questions also failed to ask about prior incidents between the resident and spouse, while later records described ongoing agitation, bruising, and behavior changes associated with the spouse’s visits.
A resident at risk for skin breakdown developed a stage 3 pressure injury due to the facility's failure to implement necessary interventions, such as frequent repositioning. Observations showed the resident was not repositioned regularly, and the prescribed wound treatment was not applied. Documentation inconsistencies further highlighted the deficiency, as the care plan did not address the resident's risk for pressure injuries, and the wound location was often misidentified.
The facility failed to properly clean and disinfect glucometers between uses, as observed with an RN and an LPN who did not follow the manufacturer's guidelines for disinfection. The glucometers were either not cleaned or not kept wet for the required time, leading to a deficiency in infection control practices on two units.
The facility failed to follow professional standards for medication administration, resulting in deficiencies for three residents. An LPN left medication at a resident's bedside and pre-prepared a patch without immediate administration. Another LPN stored unlabeled medications in a cart, and an RN stored crushed medication mixed with pudding. These actions violated the facility's policy requiring immediate administration or disposal of medications.
The facility failed to effectively implement an antibiotic stewardship program, as it did not track or monitor antibiotic use for four residents. Short-term antibiotics for two residents and long-term/prophylactic antibiotics for two others were not documented or monitored. Staff interviews revealed inadequate systems and lack of awareness regarding antibiotic checklists.
The facility failed to honor the preferences of two residents regarding their daily care routines. One resident, who was cognitively intact, was not asked about his preferences for waking up or going to bed, and his care plan did not reflect his choices. Another resident, with moderate cognitive impairment, preferred to stay up late and resisted wearing his CPAP when approached too early, leading to aggressive behavior. Staff interviews revealed a lack of awareness and a system to document and follow resident preferences.
The facility failed to provide appropriate care for two residents with limited mobility, leading to deficiencies in maintaining or improving their range of motion (ROM). One resident was observed without contracture therapy devices despite having a care plan, while another was not placed on a ROM maintenance program after physical therapy was discontinued. The facility's policies on splints and restorative nursing were not followed, resulting in a lack of appropriate treatment and services.
A facility failed to maintain a medication error rate below five percent, with two errors observed. A nurse administered eye drops incorrectly to a resident, and an LPN did not prime an insulin pen before use, potentially affecting dosage accuracy. Staff interviews confirmed the necessity of following proper procedures.
A resident with type II diabetes did not receive the correct insulin dose due to an LPN's failure to prime the insulin pen before administration. The facility's policy requires adherence to the Ten Rights of Medication Administration, but the LPN did not follow the manufacturer's guidelines, resulting in a significant medication error.
The facility failed to properly store and label medications on two units, with medications not in original containers and stored alongside food items. An RN admitted to borrowing sodium tablets and placing them in a medication cup, unaware of the unsafe practice. The DON confirmed the importance of storing medications in original containers and separately from food.
Incomplete Abuse Investigation Involving Resident and Spouse
Penalty
Summary
The facility failed to thoroughly investigate allegations of physical abuse involving a resident and his spouse after an incident in which the spouse made contact with the resident’s chest while the resident was asking her to leave and he was moving closer to her. The investigation documented that the witness separated the resident and spouse and that the spouse left the facility, but it did not include documentation of when the spouse was interviewed or what questions were asked. It also did not include a statement from the registered dietitian who witnessed the event to clarify exactly what was seen regarding the alleged pushing. The investigation record also did not show documentation that the alleged assailant was unable to enter the facility during the investigation process, and it did not document when education was provided to the spouse about safety and de-escalation. Staff interviews completed after the incident asked whether they witnessed the altercation and whether they had ever seen a family member be aggressive with any resident, but the questions did not ask whether staff had any knowledge of prior incidents between the resident and his spouse. The resident was on 1:1 supervision for an unrelated incident and remained on 1:1 supervision for safety. A later incident involved the same resident and spouse when the spouse became agitated while attempting to place shoes and glasses on the resident. The resident was assessed, bruising on the arm was noted, and two witness statements were taken. Interviews later described the spouse as controlling, aggressive, and verbally upsetting to the resident, with multiple staff reporting that the resident cried, became agitated, or had behavior changes after visits. The resident had dementia, was resistant to care, and had a history of agitation, wandering, and invading others’ space, but the deficiency centered on the incomplete investigation of the abuse allegation and the lack of thorough documentation surrounding the first incident.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and treat pressure injuries for Resident #42, who was dependent on staff for all care and mobility. The resident, known to be at risk for skin breakdown, developed a stage 3 pressure injury on the left gluteal fold. The care plan for the resident did not include interventions for frequent repositioning to prevent pressure injuries, and staff observations revealed that the resident was not repositioned frequently enough to prevent further pressure injuries. During the survey, it was observed that Resident #42 remained in the same position for extended periods without staff intervention to reposition her. On multiple occasions, staff did not enter the resident's room to reposition her, even during continuous observations. Additionally, when the wound care physician assessed the resident, the physician-ordered wound treatment was not in place, indicating a lack of adherence to prescribed care protocols. The facility's documentation was inconsistent and inaccurate regarding the location of the resident's pressure injury. The care plan did not address the resident's risk for pressure injury, and the documentation frequently misidentified the location of the wound. Interviews with staff, including the wound care physician, assistant director of nursing, and certified nurse aides, confirmed that the resident should have been repositioned frequently to prevent the development of pressure injuries, which was not done, leading to the deficiency.
Inadequate Cleaning of Glucometers
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in the cleaning and disinfection of glucometers, which are used for blood glucose monitoring. Observations revealed that a registered nurse (RN) used an unlabeled glucometer to check a resident's blood glucose level and returned it to the medication cart without cleaning or disinfecting it. Similarly, a licensed practical nurse (LPN) used another unlabeled glucometer for a different resident and attempted to clean it with a PDI Sani Cloth disinfecting wipe. However, the glucometer was not kept visibly wet for the required two minutes as per the manufacturer's guidelines. Interviews with the staff, including the LPN and the Director of Nursing (DON), confirmed that the facility's practice was not in line with the manufacturer's guidelines for cleaning and disinfecting glucometers. The LPN acknowledged that glucometers should be cleaned after each use and allowed to dry for two minutes. The DON admitted that the staff had been following incorrect guidance and emphasized the need to adhere to the manufacturer's instructions for proper disinfection. This deficiency was observed on two of the four units in the facility, indicating a systemic issue in the infection control practices related to glucometer use.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for three residents, leading to deficiencies in safe medication practices. For Resident #24, a 74-year-old with chronic obstructive pulmonary disease and other conditions, the LPN left a medication cup containing torsemide at the bedside after the resident refused it, posing a risk of ingestion by others. Additionally, the LPN pre-prepared a lidocaine patch but did not administer it immediately, storing it in the medication cart instead. For Resident #47, a 77-year-old with severe cognitive impairment, an unlabeled medication cup with multiple tablets was found on a medication cart. The LPN responsible stated that she was unable to administer the medications due to the resident being engaged with activities staff and had stored the medications in the cart instead of disposing of them as required. Resident #157, a 73-year-old with anoxic brain damage, had his medications crushed and mixed into chocolate pudding, which was then stored in a medication cart. The RN explained that the resident refused to take the medication until dinner, and she did not dispose of it to avoid wastage. These actions violated the facility's policy and professional standards, which require immediate administration or disposal of medications once prepared.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of tracking and monitoring of antibiotic use for four residents. The facility did not track short-term antibiotics prescribed for two residents, nor did it track long-term or prophylactic antibiotics for two other residents. This deficiency was identified through record reviews and staff interviews, which revealed that the facility did not have a system in place to ensure the appropriateness of prescribed antibiotics. For Resident #103, there was no documentation in the electronic medical record (EMR) to indicate that a urinalysis or cultures and sensitivity tests were completed at the hospital before prescribing Amoxicillin for a urinary tract infection (UTI). Additionally, there was no infection surveillance line listing report to monitor the resident's antibiotic use. Similarly, for Resident #84, there was no documentation of an antibiotic checklist for the prescribed Keflex, nor was there an infection surveillance report to ensure the appropriateness of the antibiotic use. Resident #73 was prescribed Nitrofurantoin for UTI prophylaxis, but there was no documentation of an antibiotic checklist or infection surveillance reports for several months. Resident #60 was also prescribed Nitrofurantoin for recurrent UTI prophylaxis, but the infection surveillance reports failed to document the resident's continued use of the antibiotic or whether the McGeer's criteria were met. Staff interviews revealed that the facility's current system for tracking antibiotic use was inadequate, and there was a lack of awareness among staff regarding the need for antibiotic checklists.
Failure to Honor Resident Preferences in Daily Care
Penalty
Summary
The facility failed to honor resident choices, specifically for two residents, by not establishing an effective system to allow residents to make choices regarding their daily care. Resident #25, who was cognitively intact and dependent on staff for all activities of daily living, expressed that he was not asked about his preferences for waking up or going to bed. The resident reported that staff would come too early to get him up and would not return if he refused. The care plan and Kardex did not document his preferences, and there was no established schedule for his daily routine. Resident #84, who had moderate cognitive impairment and exhibited aggressive behaviors, was also affected by the facility's failure to identify and accommodate his preferences. The resident preferred to stay up late watching television and consistently refused to wear his CPAP when approached too early. Despite his resistance, the facility did not adjust his care plan to reflect his preferences, leading to episodes of verbal and physical aggression. The staff's attempts to enforce the CPAP usage without considering his preferences contributed to his non-compliance and aggressive behavior. Interviews with staff revealed a lack of awareness and a system to determine and document resident preferences. Registered nurses and CNAs were unsure of who was responsible for asking residents about their preferences, and there was no established schedule for assisting residents with their daily routines. The activity director conducted assessments that included resident preferences, but there was no process to ensure this information was communicated to the nursing staff. The nursing home administrator acknowledged the absence of a system to apply resident preferences in practice.
Failure to Provide Appropriate ROM Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents with limited mobility, leading to deficiencies in maintaining or improving their range of motion (ROM). Resident #26, who had hemiplegia and contractures following a stroke, was observed multiple times without any contracture therapy devices on his right hand, despite having a care plan that included the use of a washcloth to prevent worsening contractures. The staff did not apply the washcloth as required, and the resident did not refuse care on the days he was observed without the splint. Resident #25, who was cognitively intact and dependent on staff for all activities of daily living, reported that he was not placed on a ROM maintenance program after his physical therapy was discontinued. The resident expressed a desire to get up and move around, but stated that he was left in bed without any ROM exercises. The physical therapy discharge summary had recommended a restorative program, but the MDS nurse overseeing the restorative program was unaware of this recommendation until the survey process began. The facility's policies on splints and restorative nursing were not followed, resulting in a lack of appropriate treatment and services for the residents. The MDS nurse admitted there was a breakdown in the system, as she did not receive a referral from therapy to place Resident #25 on a restorative program. This oversight contributed to the failure to implement the necessary interventions to maintain or improve the residents' ROM.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two errors out of 40 opportunities during a medication administration observation. One error involved a registered nurse administering Dorzolamide HCL Ophthalmic Solution 2% to both eyes of a resident, despite the physician's order specifying administration to the left eye only. This deviation from the prescribed order was observed during a medication round. Another error was identified when a licensed practical nurse attempted to administer Basaglar insulin to a resident without priming the insulin pen. The priming process, which involves drawing up two units of insulin to remove air from the needle, was not performed, potentially affecting the accuracy of the insulin dose administered. Interviews with the involved staff and the director of nursing confirmed the necessity of priming insulin pens to ensure the correct dose is delivered, highlighting a lapse in adherence to proper medication administration procedures.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The incident involved a resident who was 74 years old, diagnosed with severe obesity and type II diabetes with neuropathy. The resident was prescribed Basaglar KwikPen insulin to be administered subcutaneously twice daily. During an observation, an LPN was seen preparing and administering 35 units of Basaglar insulin without priming the pen with two units of insulin as required by the manufacturer's guidelines. This step is crucial to remove air from the needle and ensure the correct dose is administered. Interviews with the LPN, an RN, and the DON confirmed that the insulin pen should have been primed with two units of insulin before dialing the correct dose. The LPN acknowledged the oversight, and both the RN and DON reiterated the importance of priming to ensure the resident receives the correct dose. The facility's medication administration policy emphasizes adherence to the Ten Rights of Medication Administration, which includes ensuring the right dose is given. However, in this instance, the failure to prime the insulin pen led to a significant medication error for the resident.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored and labeled according to professional standards on two of its four units. Specifically, medications were not stored in their original containers, and medications were stored in a non-sanitary manner alongside food items. During an observation of unit medication cart #1, a plastic medication cup containing five white tablets labeled 'sodium' was found, indicating that the medication was not in its original container. Additionally, multiple unopened pudding cups were stored in the same drawer as medications. Similar findings were observed on unit medication cart #2, where multiple unopened pudding cups were also stored with medications. Interviews with staff revealed a lack of awareness regarding proper medication storage practices. A registered nurse admitted to borrowing sodium tablets from another cart and placing them in a medication cup for later use, unaware that this was unsafe. The pudding cups were reportedly stored in the medication carts for use during medication administration. The director of nursing confirmed that all medications must be stored in their original labeled containers to prevent medication errors and that storing medications with food items was not sanitary.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 55 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pueblo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Ridge Care And Rehabilitation | 1.5 mi | ★★★★★ | 20 | 1 |
| Pueblo Heights Nursing And Rehabilitation | 1.5 mi | ★★★★★ | 1 | 1 |
| Center At Park West Llc, The | 3.8 mi | ★★★★★ | 6 | 0 |
| High Plains Post Acute Llc | 3.8 mi | ★★★★★ | 6 | 0 |
| Rock Canyon Respiratory And Rehabilitation Center | 5.5 mi | ★★★★★ | 1 | 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.