AURORA, CO - Federal inspectors cited University Heights Care Center for failing to prevent repeated physical abuse after finding that staff members routinely avoided a resident with known aggressive behaviors rather than following established safety protocols designed to protect other residents from harm.
The complaint investigation, completed on March 26, 2025, at the facility located at 656 Dillon Way in Aurora, revealed a pattern in which certified nurse aides and nursing staff acknowledged they would simply "give space" to a physically aggressive resident rather than intervening to shield other residents from attacks. The citation, issued under F-600 (freedom from abuse) and F-744 (treatment and services for behavioral health), documented the facility's failure to implement its own comprehensive care plan interventions.
Staff Acknowledged Avoiding Aggressive Resident
The investigation centered on a resident identified in the report as Resident #2, who had a documented history of physical aggression toward both fellow residents and staff members. According to the inspection findings, this resident would yell, scream, and attempt to scratch others, with episodes frequently triggered when other residents moved too close in common areas such as hallways.
What made the findings particularly concerning was not the resident's behavior itself — behavioral challenges are common in long-term care settings — but the staff's admitted response to it. Multiple employees told investigators they chose to distance themselves from the resident during aggressive episodes rather than positioning themselves between the resident and potential targets.
One certified nurse aide told inspectors she "would give Resident #2 space when she was having a bad day." The aide stated she did not attempt to walk between the aggressive resident and other residents coming down the hallway to ensure they were not targeted. Her reasoning was straightforward: she was concerned that getting too close during these episodes would result in being hit or scratched herself.
A registered nurse provided similar testimony, confirming that staff "gave Resident #2 space and would back away from her when she was upset." The nurse acknowledged that the facility did not provide the resident with one-to-one supervision when she moved about the facility and that staff did not follow the resident down hallways to physically position themselves as a barrier between her and other residents.
Care Plan Existed But Was Not Followed
The gap between what the facility had planned and what actually occurred on the floor represented the core deficiency. University Heights Care Center had developed a comprehensive care plan for Resident #2 that included specific interventions to manage her behavioral triggers and protect other residents. However, the investigation revealed these interventions were not consistently implemented by frontline staff.
The facility's director of nursing provided inspectors with detailed knowledge of the resident's behavioral profile. According to the director, Resident #2 had been institutionalized at a young age and had difficulty trusting others. She was described as very protective of her belongings and personal space, with a "large personal bubble that was not always obvious to others." The resident was also described as paranoid about people whispering or talking about her.
The director outlined what staff should have been doing: when Resident #2 was having a difficult day, floor staff were supposed to notify management so that a trusted staff member with an established rapport could sit with her. Staff were expected to monitor the resident closely when she left her room frequently, as that behavior could signal an escalating day. Most critically, staff were supposed to walk alongside the resident in hallways, positioning themselves between Resident #2 and any approaching residents to prevent confrontations.
The nursing home administrator confirmed that the interventions identified in the comprehensive care plan "could not be evaluated to be effective or ineffective without implementation by all staff" — an acknowledgment that the care plan was not being carried out as written.
Why Unimplemented Care Plans Create Serious Risk
When a care facility identifies a resident's behavioral triggers and develops interventions but fails to implement them, the resulting gap creates a predictable pattern of harm. In this case, the facility had the clinical knowledge to understand that Resident #2's aggression was triggered by perceived invasions of personal space, particularly in confined areas like hallways. The care plan reflected appropriate clinical judgment. The breakdown occurred at the implementation level.
In skilled nursing facilities, behavioral care plans are not suggestions — they are required clinical documents that must be followed by all staff members who interact with the resident. Under federal regulations, facilities are obligated to ensure that residents are free from abuse, including abuse perpetrated by other residents. This obligation requires facilities to take proactive measures when a resident has a documented pattern of aggression.
The standard of care for managing resident-to-resident aggression includes several key components. First, thorough behavioral assessment to identify triggers, patterns, and warning signs. University Heights appeared to have completed this step adequately. Second, development of individualized interventions — also completed. Third, consistent implementation of those interventions across all shifts and all staff — this is where the facility failed.
Physical aggression between residents in nursing homes can result in injuries ranging from bruises and scratches to fractures and head trauma, particularly among elderly residents who may be frail, on blood-thinning medications, or have conditions such as osteoporosis that increase fracture risk. Even seemingly minor scratches can pose infection risks for immunocompromised older adults.
Reactive Measures Replaced Preventive Protocols
The inspection findings painted a picture of a facility that had shifted from a preventive approach to a reactive one. Rather than implementing the proactive interventions outlined in the care plan — monitoring, escorting, and physically buffering the resident from others — staff defaulted to responding after incidents occurred.
One CNA told investigators that when incidents happened, staff "usually addressed the cause of the issue and gave her some space" and would separate the residents by taking Resident #2 to her bedroom. A registered nurse described the facility's post-incident protocol as placing the resident on 15-minute safety checks for three days following a physically aggressive episode with another resident.
While post-incident monitoring is an appropriate component of a behavioral management strategy, it cannot serve as a substitute for the preventive measures that should occur before an incident takes place. Fifteen-minute check intervals also leave substantial windows during which a mobile resident could encounter and potentially harm other residents without staff intervention.
The facility's administrator noted that Resident #2 had access to a companion program through her insurance that would provide one-to-one support once or twice a week for one to two hours. While beneficial, this level of coverage — a few hours per week — falls far short of the continuous monitoring and intervention that the resident's behavioral pattern required during periods of agitation.
Staff Safety Concerns Highlight Training Gaps
The candid admissions from multiple staff members about their reluctance to physically intervene during aggressive episodes point to a broader issue: inadequate training and support for frontline caregivers managing residents with behavioral challenges.
Staff members across multiple roles — CNAs and registered nurses alike — expressed concern about their own physical safety when interacting with Resident #2 during episodes. While these concerns are legitimate, they indicate that the facility had not provided sufficient training in safe intervention techniques or adequate staffing levels to manage the situation safely for both staff and residents.
Behavioral management in long-term care settings requires staff to be trained in de-escalation techniques, safe physical positioning, and team-based intervention strategies. When individual staff members feel they must choose between their own safety and protecting other residents, it typically reflects a systemic failure in training, staffing, or both.
Regulatory Context and Facility Response
The citations were classified at a level of minimal harm or potential for actual harm, affecting few residents. Under federal nursing home regulations, facilities found deficient are required to submit a plan of correction detailing specific steps they will take to address the identified problems and prevent recurrence.
University Heights Care Center is required to demonstrate that all staff members have been retrained on the behavioral care plan, that monitoring and intervention protocols are being consistently implemented, and that systems are in place to verify ongoing compliance.
The full inspection report, including the facility's plan of correction, is available through the Centers for Medicare & Medicaid Services and can be accessed on the facility's profile at NursingHomeNews.org.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for University Heights Care Center from 2025-03-26 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.