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Complaint Investigation

University Heights Care Center

March 26, 2025 · Aurora, CO · 656 Dillon Way
Citations 2
CMS Rating 2/5
Beds 105
Provider ID 065337
Healthcare Facility
University Heights Care Center
Aurora, CO  ·  View full profile →
Inspection Summary

UNIVERSITY HEIGHTS CARE CENTER in AURORA, CO — inspection on March 26, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF600
Minimal harm or #2 space when she was having a bad day. CNA #3 said every time Resident #2 had a bad day, the facility Few down the hallway to ensure another resident was not targeted by Resident #2. She said was concerned if affected

F-F600: the facility failed to prevent physical abuse by Resident #2 toward other residents.

III.

Staff interviews

065337

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065337 B.

Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

University Heights Care Center 656 Dillon Way Aurora, CO 80011

According to the March 2025 CPO, diagnoses included spina bifida (a condition that occurs when the spine and spinal cord do not form properly) and Wernicke's encephalopathy (a degenerative brain disorder caused by a lack of vitamin B1).

The 2/6/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. He required partial and moderate assistance with showering and personal hygiene.

According to the MDS assessment the resident had verbal behavioral symptoms directed toward others that occurred on one to three days during the assessment review period.

2.

Resident interview

Resident #6 was interviewed on 3/26/25 at 11:56 a.m. Resident #6 said he could not recall the incident with Resident #7 on 2/12/25. Resident #6 said if someone pushed him he would not be happy and he would want to get that person out of the facility. He said if a resident was really aggressive and pushed him, he would be afraid. He said he would not be happy at all. Resident #6 said he did not have any problems with staff or residents. He said he did not feel threatened by anyone and felt safe at the facility.

3.

Record review

The behavior care plan, revised 3/9/24, documented due to his diagnosis of Wernicke's encephalopathy, Resident #6 had frequent outbursts of cursing, sometimes the outbursts had a direct cause, other times they did not.

Pertinent interventions included:

-Anticipating and meeting the residents' needs;

-Assisting the resident to develop more appropriate methods of coping and interacting by having him remove himself from the situation when he became frustrated and working on calming himself down;

-Encouraging the resident to express his feelings appropriately;

065337

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065337 B.

Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

University Heights Care Center 656 Dillon Way Aurora, CO 80011

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in AURORA, CO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from UNIVERSITY HEIGHTS CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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