Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
University Park Care Center
PUEBLO, CO · 180 certified beds · Last Life Safety survey June 11, 2024
CMS Certification Number 065231 · first certified February 1986
Ownership
Operated by LIFE CARE CENTERS OF AMERICA · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CO
19 citations — more than 58% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (November 2025 to June 2026), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was June 2024. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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6 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 19 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 15, 2019 | 6 |
| February 2, 2023 | 7 |
| June 11, 2024 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-06-11 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2023-02-02 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-06-11 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2023-02-02 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-06-11 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2023-02-02 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2024-06-11 |
| E-0030 | List the names and contact information of those in the facility. | 1 | 2019-08-15 |
What the citations cover
- Smoke Deficiencies 9
- Egress Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Services Deficiencies 2
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Egress Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Services Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 11, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 18, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 18, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 22, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 17, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 29, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 26, 2024) |
February 2, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 6, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 6, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 6, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 6, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 6, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 6, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 6, 2023) |
August 15, 2019 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (September 9, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 28, 2019) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 21, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 2, 2019) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 9, 2019) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 13, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.