Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 0 | 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 August 2026) and official state health department websites.