Cycle 1
Health 2024-06-11 · Fire 2024-06-11
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Pueblo, CO
University Park Care Center
4-star overall rating with 3-star inspections with $22,653 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
945 Desert Flower Blvd, Pueblo, CO
(719) 545-5321
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1986-02-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
194 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.84
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.36
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,821
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.04
Baseline 18.12% · Performance 19.56% · Measure score 4.04 · Achievement 4.04 · Improvement 0
Healthcare-associated infections
0
Baseline 6.44% · Performance 7.90% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.91
Baseline 37.76% · Performance 51.79% · Measure score 2.91 · Achievement 2.91 · Improvement 0
Adjusted total nurse staffing
2.01
Baseline 3.36 hours · Performance 3.65 hours · Measure score 2.01 · Achievement 2.01 · Improvement 0.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.36% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 4.35% · Lower 95% interval 6.26% |
| Discharge to community | 60.87% |
50.57%
10.3 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 55.93% · Lower 95% interval 48.41% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 32 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 79.17% |
53.69%
25.5 pts better
|
Numerator 19 · Denominator 24 |
| Discharge mobility score | 83.33% |
50.94%
32.4 pts better
|
Numerator 20 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.9% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 10% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 3.47% |
8.2%
4.7 pts worse
|
Numerator 6 · Denominator 173 |
| Staff flu vaccination coverage | 51.92% |
42%
9.9 pts better
|
Numerator 135 · Denominator 260 |
| Discharge function score | 83.33% |
56.45%
26.9 pts better
|
Numerator 20 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 23.81% |
25.2%
1.4 pts worse
|
Numerator 5 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
93.5%
3.8 pts worse
|
93.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 87.2% · Q3 87.9% · Q4 91.8% · 4Q avg 89.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.1% |
94.7%
3.6 pts worse
|
95.5%
4.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.4%
2.1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.1% · Q3 1.0% · Q4 1.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.7% |
7.4%
2.3 pts worse
|
11.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 5.6% · Q3 13.2% · Q4 17.8% · 4Q avg 9.7% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
5.0%
2.4 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 5.9% · Q3 3.4% · Q4 6.7% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
11.2%
1.5 pts worse
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 15.1% · Q3 11.2% · Q4 11.1% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.1% |
20.6%
2.5 pts better
|
16.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 19.4% · Q3 17.4% · Q4 15.1% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.7% |
15.2%
0.5 pts better
|
16.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 14.7% · Q3 15.6% · Q4 12.8% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
14.6%
0.5 pts worse
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 18.8% · Q3 13.4% · Q4 12.0% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.8%
0.6 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.5%
0.1 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 3.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
22.4%
0.2 pts worse
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 20.3% · Q3 26.5% · Q4 24.7% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
3.7%
1.1 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.8% · Q3 2.6% · Q4 3.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.2% |
76.4%
4.2 pts worse
|
81.7%
9.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.7% · Q2 60.9% · Q3 67.1% · Q4 83.8% · 4Q avg 72.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.8% |
12.8%
8 pts better
|
12.0%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.8% · Observed 4.8% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.7% |
75.6%
7.9 pts worse
|
79.7%
12 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.8% |
20.3%
2.5 pts worse
|
23.9%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 26.2% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-02 · Fire 2023-02-02
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-08-15 · Fire 2019-08-15
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-06-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-18
F · Potential for more than minimal harm
2024-06-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-06-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-17
F · Potential for more than minimal harm
2024-06-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-29
F · Potential for more than minimal harm
2024-06-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-26
F · Potential for more than minimal harm
2023-02-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-06
F · Potential for more than minimal harm
2023-02-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-06
F · Potential for more than minimal harm
2023-02-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-06
E · Potential for more than minimal harm
2023-02-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-02-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-02-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-02-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-06
F · Potential for more than minimal harm
2019-08-15
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-09-09
F · Potential for more than minimal harm
2019-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-28
F · Potential for more than minimal harm
2019-08-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-12-09
F · Potential for more than minimal harm
2019-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-11-13
E · Potential for more than minimal harm
2019-08-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-21
E · Potential for more than minimal harm
2019-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-17
G · Actual harm
2024-06-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-09
F · Potential for more than minimal harm
2024-06-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-09
E · Potential for more than minimal harm
2024-06-11
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-07-09
E · Potential for more than minimal harm
2024-06-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-09
E · Potential for more than minimal harm
2024-06-11
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-11
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-02-21
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-02-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-14
G · Actual harm
2024-01-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-21
D · Potential for more than minimal harm
2023-02-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-04
D · Potential for more than minimal harm
2023-02-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-04
F · Potential for more than minimal harm
2019-08-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-09-09
F · Potential for more than minimal harm
2019-08-15
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-09-09
E · Potential for more than minimal harm
2019-08-15
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2019-09-09
E · Potential for more than minimal harm
2019-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-02
D · Potential for more than minimal harm
2019-08-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-09-09
D · Potential for more than minimal harm
2019-08-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-09-09
D · Potential for more than minimal harm
2019-08-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-09-09
D · Potential for more than minimal harm
2019-08-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-09-09
D · Potential for more than minimal harm
2019-08-15
F743 · Quality of Life and Care Deficiencies
Health
Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable.
Corrected 2019-09-09
Penalties and ownership
What sits behind the stars
$22,653
2024-06-11
Fine
Fine · fine $22,653
Fine
$0
2024-01-08
Payment Denial
Payment Denial · denial start 2024-02-06 · 15 days
15 day denial
Ownership
Preston, Forrest
5% Or Greater Direct Ownership Interest · Individual
Cross, Cindy
Corporate Officer · Individual
Developers Investment Company Inc
Operational/Managerial Control · Organization
Fletcher, Todd
Operational/Managerial Control · Individual
Fransua, Brittnee
Operational/Managerial Control · Individual
Henry, Terry
Corporate Officer · Individual
Kinnett, Steven
Operational/Managerial Control · Individual
Laroche, Melanie
Operational/Managerial Control · Individual
Lay, Lisa
Corporate Officer · Individual
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Preston, Aubrey
Operational/Managerial Control · Individual
Pueblo Medical Investors, LLC
Operational/Managerial Control · Organization
Schmidt, Derek
Operational/Managerial Control · Individual
Swanker, Richard
Corporate Officer · Individual
Thurmond, Joan
Corporate Officer · Individual
Ziegler, James
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Pavilion At Villa Pueblo, The
Pueblo, CO
3-star overall rating with 3-star inspections with $48,912 in total fines with 10 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Pueblo Heights Nursing and Rehabilitation
Pueblo, CO
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Center At Park West LLC, The
Pueblo, CO
4-star overall rating with 3-star inspections with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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