University Heights Care Center

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS lists this home under a new chain.

• Ownership

  CMS ownership records list new owners for this home.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• CMS abuse icon

  CMS added its abuse icon to this home.

CMS lists this as a complaint inspection.

• Citation F0925. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS lists it as corrected on December 17, 2025.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on December 17, 2025.

  CMS has cited this home for F0600 3 times since 2024.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on December 17, 2025.

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• CMS abuse icon

  CMS removed its abuse icon from this home.

CMS lists this as a standard inspection.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on August 28, 2025.

  CMS has cited this home for F0880 3 times since 2022.

• Citation F0552. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on August 28, 2025.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on August 28, 2025.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on August 28, 2025.

  CMS has cited this home for F0677 2 times since 2022.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on August 28, 2025.

  CMS has cited this home for F0679 2 times since 2022.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on August 28, 2025.

  CMS has cited this home for F0686 2 times since 2022.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on August 28, 2025.

• Citation F0699. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care or services that was trauma informed and/or culturally competent.

  CMS lists it as corrected on August 28, 2025.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on August 28, 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on August 28, 2025.

  CMS has cited this home for F0761 2 times since 2022.

• Citation F0849. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

  CMS lists it as corrected on August 28, 2025.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0600. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on March 27, 2025.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 27, 2025.

  CMS has cited this home for F0689 2 times since 2022.

• Citation F0744. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  CMS lists it as corrected on March 27, 2025.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.

• Name

  CMS lists a new legal business name for this home.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Name

  CMS lists a new legal business name for this home.

• Staffing

  Total nurse staffing reported to CMS went from 3.2 to 2.8 hours per resident per day.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Name

  CMS lists a new name for this home. It was UNIVERSITY HEIGHTS REHAB AND CARE COMMUNITY.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 1 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.1 to 2.2 hours per resident per day.

CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on January 25, 2024.

• Citation F0814. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Dispose of garbage and refuse properly.

  CMS lists it as corrected on January 25, 2024.

• Citation F0838. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

  CMS lists it as corrected on January 25, 2024.

• Citation F0867. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on January 25, 2024.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 25, 2024.

• Citation F0883. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS lists it as corrected on January 25, 2024.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on January 25, 2024.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  CMS lists it as corrected on January 25, 2024.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on January 25, 2024.

  CMS has cited this home for F0804 2 times since 2022.

• Citation F0806. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on January 25, 2024.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on January 25, 2024.

• Citation F0585. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

  CMS lists it as corrected on January 25, 2024.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on January 25, 2024.

• Citation F0645. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: PASARR screening for Mental disorders or Intellectual Disabilities

  CMS lists it as corrected on January 25, 2024.

• Citation F0660. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Plan the resident's discharge to meet the resident's goals and needs.

  CMS lists it as corrected on January 25, 2024.

• Citation F0685. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.

  CMS lists it as corrected on January 25, 2024.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on January 25, 2024.

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CMS lists this as a standard inspection.

• Citation E0009. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Include a process for Emergency Preparedness collaboration.

  CMS lists it as corrected on January 25, 2024.

• Citation E0013. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop Emergency Preparedness policies and procedures.

  CMS lists it as corrected on January 25, 2024.

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CMS lists this as a standard inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

45 of 210 Colorado homes (21%) got a citation at the actual harm level in 2022.

• Citation F0686. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on September 30, 2022.

• Citation F0692. Severity G: actual harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on September 30, 2022.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on September 30, 2022.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on September 30, 2022.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on September 30, 2022.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on September 30, 2022.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on September 30, 2022.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on September 30, 2022.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on September 30, 2022.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on September 30, 2022.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  CMS lists it as corrected on September 30, 2022.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 30, 2022.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on September 30, 2022.

• Citation F0807. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

  CMS lists it as corrected on September 30, 2022.

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