The November 21 attack left the victim shaken and the aggressor with a head injury after he lost his balance and fell. Two facility staff members witnessed the altercation outside the aggressive resident's room, according to federal inspection records.
Yet the nursing home failed to update the aggressor's behavior care plan until December 23 — more than a month after the November incident and two months after an earlier attack in October.
The pattern of violence began October 21 when the same resident rammed his wheelchair into another resident's knees, causing an abrasion and whiplash. On November 21, he stood up from his wheelchair and grabbed a third resident by the collar before pushing him.
"Don't be stupid in front of my door," the aggressive resident yelled before attacking, according to a nursing progress note from the November incident.
The nursing home administrator told inspectors the brain-injured resident "was triggered by other people not using common sense" and became agitated when people knocked on his door while he could see them. He was protective of his personal belongings.
But staff interviews revealed confusion about what interventions were in place. One certified nursing aide said she wasn't aware of any behavioral interventions for the aggressive resident after the October incident. Staff were simply told to intervene if residents got too close to each other.
The social service director couldn't access old care plans because the facility had switched to a different electronic medical record system. She said she thought the aggressive behavior care plan had been resolved since there hadn't been incidents "until recently."
In the November attack, housekeeper witnessed the aggressive resident stand up and push the victim in the chest. The victim pushed back defensively, causing the aggressor to stumble and hit his head on a door frame.
"Resident #6 was upset and shaking after the incident," the housekeeper told inspectors.
The victim, who has severe cognitive impairment and dementia, was walking with a maintenance worker when the confrontation began. The aggressive resident told him to "stop acting tough in front of me" before grabbing his shirt.
A registered nurse assessed both residents after the November incident. The victim had no injuries, but the aggressor sustained an abrasion on his head and scratches on his shoulder. He was transferred to the hospital as a precaution because of metal plates in his head from previous injuries.
The aggressive resident returned the same day without complications.
Staff documented that both residents were placed on frequent checks — visual monitoring every 15 minutes for 72 hours. But inspectors found no documentation that these checks were actually completed for the aggressive resident after the October incident.
The October attack involved a different victim. The aggressive resident rammed his wheelchair into a woman's knees while she was coming in from smoking and he was going out. The impact caused a half-centimeter abrasion on her right forearm and redness above her left ankle.
The woman told staff the collision threw her back in her wheelchair, causing right shoulder and leg pain. She later reported whiplash and required physical therapy for neck tightness.
One licensed practical nurse said staff tried to watch for the female victim when she went to smoke. If the aggressive resident was in the hallway, the woman would return to her room rather than go outside.
The facility's abuse investigation concluded both incidents were substantiated abuse cases. Police, families, the ombudsman and physicians were notified each time.
The nursing home administrator acknowledged that residents' behavior care plans should be updated within a week of resident-to-resident incidents. But the aggressive resident's care plan wasn't updated for physical aggression until December 23 — four weeks after the November attack.
The social service director said the aggressive resident had previous physical aggression incidents more than a year ago, but she thought those issues had been resolved.
Federal inspectors also cited the facility for failing to have registered nurses assess residents before moving them after unwitnessed falls.
An 83-year-old woman with a history of hip fractures fell from her wheelchair December 20. A licensed practical nurse and nursing aide lifted her from the floor before a registered nurse could evaluate her. The woman complained of pain after being moved and was sent to the emergency department, where she was diagnosed with a left hip fracture requiring surgery.
"Everything slipped," the woman told staff when asked how she ended up on the floor. She asked if she had broken her back.
The facility's fall protocol policy didn't specify that registered nurses should assess residents before they're moved after unwitnessed falls, though staff interviews confirmed this was the expected practice.
A second resident also was moved from the floor by unlicensed staff before a registered nurse assessment in November. That resident sustained skin tears and bruising but wasn't hospitalized.
The director of nursing told inspectors it wasn't within a licensed practical nurse's scope of practice to conduct assessments after unwitnessed falls. She said the LPN who moved the hip fracture victim received fall training three days after the incident.
Multiple staff members confirmed that registered nurses should assess residents with unwitnessed falls before they're moved from the floor.
The regional director of quality and compliance said the facility would implement further interventions for the aggressive resident's behavior care plan, but inspectors found the pattern of delayed responses had already allowed three people to be injured.
The aggressive resident told investigators he would "slap around" the November victim before standing up and losing his balance. In the October incident, he told staff that people should get out of his way.
Staff said he had yelled at other residents before the documented attacks, but formal behavioral interventions weren't implemented until weeks after the violence escalated to physical contact.
The facility serves residents in Brush, a town of about 5,500 people in northeastern Colorado. Federal inspection records show the nursing home has struggled with ensuring qualified staff provide appropriate assessments and care planning for residents with complex behavioral needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Platte Rehabilitation and Nursing LLC from 2025-01-07 including all violations, facility responses, and corrective action plans.
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