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F0600
G

Failure to Prevent Resident-to-Resident Physical Abuse

Lander, Wyoming Survey Completed on 10-15-2025

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 residents from physical abuse by other residents, resulting in actual physical harm to two residents. Multiple incidents were documented in which one resident, who had diagnoses including schizophrenia and bipolar disorder and was cognitively intact, engaged in physical altercations with another resident. These altercations were often triggered by verbal provocations, including derogatory name-calling and accusations of theft. The aggressive behaviors included throwing objects, physical fighting, and attempts to punch, kick, or otherwise harm another resident. In several instances, staff had to intervene to separate the residents, and minor injuries such as abrasions and swelling were noted. Another resident, who had cerebral palsy, seizure disorder, and anxiety disorder, and used a motorized wheelchair, was also involved in a physical altercation with a peer. This resident, described as non-verbal and generally getting along with others except for one individual, was observed hitting and being hit by another resident after an exchange of words. The altercation resulted in visible injuries, including swelling and bruising to the eye and a small scrape. Staff and witnesses reported that the instigating resident had a history of taunting and using derogatory language toward others, which contributed to the escalation of these incidents. Interviews with staff confirmed that the resident who frequently used derogatory language was known to antagonize others and that redirection efforts by staff were not always effective. Staff also reported that some residents would attempt to avoid the instigating resident by staying in their rooms, and that fear and distress were present among those targeted. Despite the facility's policy stating that all residents would be protected from abuse and neglect, the documented incidents demonstrate that the facility did not effectively prevent or intervene in resident-to-resident abuse, resulting in physical harm and emotional distress.

See complete original report
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