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F0600
D

Failure to Prevent Resident-to-Resident Abuse

Fort Collins, Colorado Survey Completed on 05-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from abuse by another resident, resulting in both physical and verbal abuse incidents. In the first incident, a resident with severe cognitive impairment and a history of wandering entered another resident's room. The resident whose room was entered became upset, waved his fists, and contact occurred that caused the wandering resident to fall and sustain a bruise and abrasion. Both residents involved had cognitive impairments, and the incident was substantiated as physical abuse by the facility. Prior to the incident, the care plan for the wandering resident noted the risk of physical aggression and included interventions such as encouraging direct line-of-sight supervision to prevent wandering into other residents' rooms. In the second incident, another resident with severe cognitive impairment and agitation was verbally abused by the same resident who had previously engaged in physical aggression. As the resident in a wheelchair approached the aggressor's room and touched a stop sign on the door, the aggressor became visibly angry and yelled loudly, causing the other resident to appear scared and confused, with observable physical signs of distress. Staff immediately intervened to separate and redirect the residents. The care plan for the verbally abused resident included interventions for wandering and agitation, but the incident still occurred. Staff interviews revealed that the resident who committed the abuse was known to display verbal aggression, particularly in the afternoon, and that staff were aware of his behavioral triggers. On the day of the verbal abuse, staff were occupied with other residents and unable to prevent the incident. The social services director was not aware of the verbal abuse incident until informed during the survey, indicating a lack of immediate awareness and response to the event. The facility's failure to prevent these incidents resulted in residents not being kept free from abuse as required by policy.

See complete original report
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