F0600

D

Failure to Prevent and Manage Repeated Resident-to-Resident Physical Abuse

Englewood, Colorado Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite known behavioral histories and prior altercations. Facility policy dated 5/3/23 states that residents have the right to be free from abuse, neglect, and all forms of physical and mental mistreatment. In two separate incidents on 12/12/25 and 12/14/25, a cognitively intact resident with COPD and peripheral vascular disease was physically struck by another resident with schizophrenia, nicotine dependence, and a history of head injury and severe cognitive impairment. In both incidents, the victim was backing through a doorway in a wheelchair while another resident guided the chair, and the assailant resident hit her—first on the upper back and then on the head, resulting in a small bump. The facility’s own investigation documented that the assailant had five other documented instances of physical aggression in the past year and a care plan noting a history of peer-to-peer altercations and potential for physical aggression.

Another deficiency event involved a resident with heart failure, opioid abuse, and bipolar disorder physically abusing her roommate, a resident with a brain tumor, obesity, repeated falls, and moderate cognitive impairment who required assistance with dressing. The facility investigation documented that the aggressor resident became upset after believing the roommate was wearing her shirt, attempted to remove the shirt, and then threw juice in the roommate’s face. The roommate reported that she was accused of wearing the shirt, was hit on the chin, and had juice poured on her. The investigation also noted that the victim was incapable of dressing herself and would not have been able to put on the shirt without assistance, and that the aggressor had a prior history of verbally aggressive behavior toward the same roommate, including hostile and profane remarks and a statement that she hoped the roommate would choke on her own blood. The aggressor’s care plan already identified potential for verbally aggressive behaviors, often involving cigarettes and money, and included interventions such as monitoring interactions with the roommate and separating them if altercations arose.

A further incident of physical abuse occurred between two residents when one resident, while going to bed and wheeling backwards in a wheelchair, accidentally bumped into another resident, who then hit the wheelchair user in the head. The investigation documented that the bumped resident then hit back in retaliation, although one of the residents later denied retaliating and reported feeling that staff did not separate the residents and laughed when she was hit, leaving her feeling helpless and unable to prevent future incidents. Staff interviews showed inconsistent understanding of what constitutes abuse, with one LPN stating she was unsure exactly what line needed to be crossed for an event to constitute abuse, while others described any hitting or nonconsensual touching as abuse. The nursing home administrator acknowledged ongoing behavioral issues with one of the aggressive residents and referenced other residents bumping into him, as well as a clothing mix-up contributing to the roommate altercation. Across these events, the facility’s failure to prevent repeated peer-to-peer physical aggression, despite known behavioral risks and prior incidents, resulted in multiple residents being subjected to physical abuse.

Staff interviews further highlighted the environment in which these incidents occurred. One CNA reported working often with two of the aggressive residents and stated she tried to de-escalate them by talking and giving them space when they became agitated, and believed these strategies generally prevented incidents. Another LPN stated that if a resident was getting agitated, she would try to calm and de-escalate them and monitor them frequently, and another LPN described separating residents and reporting abuse to administration if witnessed. The maintenance director, who is also a CNA, stated that the facility generally responded to physical abuse by keeping residents separated and moving them to separate floors, and noted that clothing was labeled and should be double-checked by CNAs when assisting residents with dressing. Despite these stated practices and care plan interventions, the documented events show that residents with known behavioral risks and cognitive impairments engaged in repeated physical aggression toward other residents, and victims reported ongoing fear and nervousness when in the same room as their aggressors.