University Park Care Center
University Park Care Center in PUEBLO, CO — inspection on November 20, 2025.
Found 1 citation. 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.
Inspection Findings
the following documents on 11/21/25 at 7:51 p.m., after the survey exit.
The 8/2/25 incident witness statement revealed the RD was asked to perform a repeat demonstration of the RD's witnessed events regarding Resident #1's spouse and Resident #1. Resident #1's spouse was upset Resident #1 did not want to sit and visit with her as he had a tendency to pace the hallways frequently at that time during one-on-one sessions.
The spouse became upset and asked the resident if he wanted her to leave and he could spend time with his girls, referring to the female staff members, such as CNAs and nursing staff. A majority of the one-on-one staff members were females as opposed to males. Resident #1 had a tendency to get into others' personal space and he did this with his spouse during the conversation in which his spouse placed her hands on his chest and applied pressure to create distance of approximately three to six inches.
The shove was not hard, in the RD's opinion based on her witness testimony, and was not meant to be aggressive or abuse, but was meant to create distance between the two of them.
The RD separated the resident and the spouse.
The spouse left the facility and the RD spoke with the ADON, the SSD and the NHA.
The SSA handled the investigation as he was the associate working in social services the day the incident occurred.
The repeat demonstration included the RD to verbally describe the situation and what occurred along with physically showing the team the forcefulness or lack of forcefulness regarding the above situation.
The DON described the return demonstration as the RD said the spouse was asked to leave so the resident could be with the girls.
The spouse and the resident exchanged words.
The resident started to walk towards his spouse.
The RD said the spouse pushed the resident to create space between the two of them.
The RD said it was a shove but the resident barely moved.
The RD said multiple times that the spouse was trying to create space between the spouse and the resident.
The RD was asked to complete a return demonstration with the SSD acting as the resident.
The RD stood in front of the SSD with feet slightly apart.
The RD's arms were straight out and her palms towards the SSD.
The RD asked the SSD to walk towards the RD and the SSD walked forward directly into the RD's hands.
The RD palms were on her upper chest and shoulder.
The SSD was not pushed by the RD.
The 8/4/25 SSD note revealed she spoke with the spouse.
The SSD asked the spouse about the 8/2/25 incident.
The spouse denied pushing the resident and denied doing anything considered aggressive.
The spouse said she was frustrated with the resident and told him to stop coming towards her.
The spouse said she did not understand why she was asked to leave the facility.
The SSD informed the spouse the facility took physical abuse allegations seriously and explained the investigation procedure.
The spouse said she understood the procedure.
The SSD requested to call the spouse along with her three children to let them know the outcome of the investigation.
The spouse agreed and agreed to refrain from visits until the investigation was concluded.
The 8/6/25 SSD note revealed she spoke with the spouse and the resident's three children on a conference call.
The SSD explained that due to the incident that occurred on 8/2/25, the spouse was to allow the CNAs to provide care and a one-on-one sitter would be in the room at all times with the resident, even when the spouse visited.
The SSD encouraged the spouse to walk away or possibly take a drive if she became overwhelmed or frustrated with the resident during visitation.
The SSD explained that all transportation for appointments for the resident could be provided by the facility and if the family wanted to transport the resident that one of the children, son-in-law or grandchildren needed to accompany them in the vehicle.
All parties stated they understood the education and only wished to keep the resident safe.
The SSD explained the facility had the resident's safety and well being as their priority as well as their other residents in the unit.
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