F0600

D

Failure to Prevent Resident-to-Resident Physical Abuse on Secure Unit

Fort Collins, Colorado Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident on a secure memory unit. Facility policy defined abuse and neglect and required identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as deployment of sufficient, trained staff and appropriate supervision. Despite this, the facility did not prevent resident‑to‑resident altercations involving a resident with dementia and behavioral issues who physically struck two other residents. The facility’s abuse investigations, care plans, and documentation show gaps in behavioral assessment, communication support, and supervision that contributed to these incidents.

In the first incident, a CNA observed a resident with severe cognitive impairment and dementia enter another resident’s room. As the CNA approached to redirect him, she heard the cognitively intact resident in the bathroom tell the intruding resident to get out, followed by a sound like a punch. When the CNA entered, she redirected the intruding resident out of the room and noted a scratch on the other resident’s neck. The victim reported that the other resident punched him three or four times and that something sharp from the assailant’s knuckles scratched him. A physician note documented that the victim had an altercation with another resident who scratched his neck, resulting in a small skin tear approximated with steri‑strips. Staff on the unit reported that contact had been made and that the injury was most likely from the assailant’s nail. The facility’s investigation concluded the allegation could not be substantiated or unsubstantiated and did not explore alternative causes for the neck injury, despite the victim’s statements and staff reports of hearing a punch and observing contact.

In the second incident, a CNA was the only staff member present on the secure unit while the nurse was on another unit. She heard two male residents’ voices escalating in the hallway and, after quickly finishing care in a room, found two residents in a verbal dispute. As she positioned herself between them to deescalate, the same resident with dementia approached and swung with a closed fist, making contact with one disputing resident’s cheek. A nursing progress note documented that the resident walked by and punched the other resident in the face. The victim, who had severe cognitive impairment and dementia, denied being hit, and no apparent injuries were found on assessment. The assailant denied involvement, and there was no indication that an interpreter was used during his interview, even though his primary language was documented as Spanish and staff reported difficulty communicating with him when he was agitated. Care plans for the assailant and the victim referenced behavioral risks and the need for close supervision, frequent checks, and redirection, but did not specify effective, resident‑specific redirection techniques or clearly defined alternative communication tools for the Spanish‑speaking resident. Staffing on the secure unit routinely consisted of one nurse (also assigned to another unit) and one CNA, resulting in periods when only one staff member was present to both assist residents and monitor behaviors.