Aviva at Fitzsimons: Fall Left Bone Exposed - CO
He had fallen more than four hours earlier.
The fall happened around 4:30 p.m. on August 13, 2025. Staff brought him back to his room. The facility nurse did not call the hospice company until around 6:30 p.m., two hours after the fall. Based on the information the facility provided, the hospice nurse said she had no reason to believe there was an urgent problem. She did not arrive until nearly 9:00 p.m.
Four and a half hours passed between the fall and the moment anyone called an ambulance.
The hospice nurse described what she found in a telephone interview with inspectors on August 26. She said she felt the bump through his pants before anything was removed or examined. She did not need an X-ray to know something was wrong. She called for emergency services immediately.
The nursing home administrator, interviewed that same afternoon, told inspectors she believed the facility had proper interventions in place to ensure the safety of all residents following the incident.
That was the administrator's full response.
Federal inspectors cited the facility for a violation at the "actual harm" level, the finding reserved for cases where a resident suffered real injury, not theoretical risk. The citation fell under F0689, which covers the prevention of accidents and the facility's responsibility to respond to them.
What the inspection record does not contain is any account from facility staff of what they observed when they brought Resident 1 back to his room after the fall. It does not explain why the nurse waited two hours before calling hospice. It does not describe what assessment, if any, was conducted in the time between the fall and that call. The record does not say whether anyone checked his leg, whether he reported pain, or whether anyone documented his condition in the hours he spent in his room before the hospice nurse arrived.
What it does contain is the hospice nurse's account, specific and linear. She was called at 6:30. She was told enough to believe the situation was not urgent. She arrived at 9:00. She touched his leg. She felt bone.
The inspection covered a complaint and concluded August 26, 2025. The harm level finding means inspectors determined Resident 1 was actually injured, not merely placed at risk. A displaced fracture serious enough to be felt through clothing, hours after a fall, in a man on hospice care, is the outcome the finding describes.
The administrator's belief that proper interventions were in place was offered after all of that had already happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviva At Fitzsimons from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 4, 2026 · Our methodology
AVIVA AT FITZSIMONS in AURORA, CO was cited for violations during a health inspection on August 26, 2025.
He had fallen more than four hours earlier.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.