F0600

E

Failure to Prevent Resident-to-Resident Abuse in Dementia and Behavioral Care Units

Lakewood, Colorado Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by other residents, despite known behavioral risks and repeated resident‑to‑resident altercations. The facility’s abuse policy states that residents have the right to be free from abuse, neglect, and exploitation, including freedom from verbal, mental, sexual, or physical abuse. Surveyors found that six residents experienced abusive interactions that met the regulatory definition of abuse, even when the facility sometimes concluded that incidents were not intentional or did not substantiate them. Many of the involved residents had severe dementia, behavioral disturbances, wandering, and histories of aggression, yet the facility did not consistently implement preventive measures to keep them and others safe.

One resident with severe dementia and wandering and aggressive behaviors was physically abused on three separate occasions by three different residents. In one incident, a roommate with Alzheimer’s disease and a history of several resident‑to‑resident altercations grabbed at this resident’s feet and tried to pull him out of bed while yelling that it was his room. In another incident, a resident with severe dementia and aggressive behaviors physically redirected the same wandering resident out of her room, causing him to lose balance and fall. In a third incident, a resident with severe cognitive impairment and a history of physical behaviors pushed this same wandering resident and yelled at him to get out of his room after the resident entered without invitation. Staff interviews confirmed that residents frequently wandered into others’ rooms and that staff generally redirected them only after they had already entered, with no proactive measures in place to prevent unauthorized room entry.

Other residents were also subjected to physical abuse. One resident with severe dementia and delusional beliefs was knocked to the floor and struck with a wheelchair by a resident with Alzheimer’s disease who became highly agitated; in a separate event, the same victim was pushed in the hallway by another resident with severe dementia and a known potential for physical aggression, who told her to walk faster. Another severely cognitively impaired resident was physically abused twice: once when her roommate, who had severe dementia and a known tendency to become aggressive when her personal space was invaded, took her face in her hands and pushed it away, and again when a different resident, with impaired coping skills and poor impulse control, became verbally distressed over a preferred chair in the common area, reached toward her, and during the altercation she fell and sustained a forehead laceration requiring first aid. In another incident, a resident with dementia wandered into the room of a resident with severe dementia and behavioral problems and grabbed and scratched her hand.

The facility also failed to protect two cognitively impaired or partially impaired male roommates from escalating verbal and physical abuse toward each other. One resident with memory deficits, poor impulse control, and a behavior care plan noting potential for physical aggression reported that tension over television noise had been building between him and his cognitively intact roommate. On the day of the incident, he described flipping off his roommate, exchanging verbally hostile remarks, asking if the roommate wanted to fight, and then engaging in a shoving match after the roommate hit his leg, which resulted in him falling and sustaining a small abrasion to his knee. Staff interviews indicated that abuse was understood to include bullying and hitting, and that the altercation was preceded by days of increasing tension between the two residents. Overall, staff acknowledged frequent wandering, frequent entry into others’ rooms, and reliance on redirection after the fact, rather than preventive strategies, in a unit where many residents had dementia, mental health issues, and known behavioral risks.

In several investigations, the facility did not substantiate abuse despite clear physical contact and aggression, citing lack of malicious intent or dementia‑related agitation, and sometimes made no changes to care plans or room assignments. For example, the facility concluded that a wheelchair collision and repeated contact with a resident on the floor was due to impulsive propulsion rather than an attempt to harm, and it unsubstantiated incidents where one resident pushed another in the hall and where a roommate pushed another resident’s face away. In another case, the facility’s investigation of a fall with injury following a confrontation over a preferred chair did not clearly describe the sequence of events and focused on the absence of intentional harm rather than the regulatory definition of abuse. Staff interviews further revealed that many resident‑to‑resident altercations occurred at night or on weekends when agency staff were present, and that there were no measures in place to prevent residents from entering others’ rooms, despite widespread wandering and known behavioral triggers.