F0600

E

Failure to Protect Residents From Repeated Resident-to-Resident Physical Abuse

Trinidad, Colorado Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite having an Abuse Investigating and Reporting policy requiring all reports of resident abuse to be reported and investigated by facility management. Surveyors identified six residents who were victims and/or assailants in substantiated incidents of physical abuse. The facility’s own investigations confirmed that altercations occurred and resulted in injuries, yet the pattern of events showed that residents with known behavioral histories were not adequately protected from each other, and that documentation of these incidents in the medical record was inconsistent or missing.

In one incident, a resident with severe cognitive impairment and impaired mobility was seated near another resident in a wheelchair. When the first resident asked the second not to run into her with his wheelchair, the second resident struck her in the face, bending her eyeglasses and causing lacerations on the bridge of her nose that required emergency department evaluation and first-aid treatment. The assailant had diagnoses including dementia, anxiety, traumatic brain injury, and epilepsy, and was dependent on staff for mobility. Although his MDS assessment documented no physical or verbal behaviors toward others, a nurse progress note days later described that he had been observed raising his hand toward the same resident, and a physical aggression care plan was initiated after that observation, indicating a pattern of aggressive behavior.

In another incident, a resident with dementia, severe cognitive impairment, and wandering behavior exited her room and approached a male resident in the hallway, attempting to hold his arm and walk with him. The male resident, who had Alzheimer’s disease and dementia with behavioral disturbance and a documented history of physical behaviors toward others, responded by pushing her, causing her to lose balance and fall, resulting in a skin tear on her forearm. His care plan already identified physical aggression and interventions such as redirection and maintaining a calm environment, yet there was no corresponding nurse progress note in his electronic medical record documenting this altercation. A subsequent altercation involving the same male resident occurred in a common area when he swung his feet over a chair arm, bumped another resident, and then engaged in a mutual physical exchange of kicking and slapping after the other resident pushed his foot away. Again, there were no corresponding nurse progress notes in either resident’s record describing this event.

A further substantiated incident involved two residents in wheelchairs in a common area who were heard yelling at each other. Staff found them rolling away from each other, and one resident was found to have an abrasion above his right eye. One of these residents had mild cognitive impairment and no documented behavioral symptoms toward others on the MDS, while the other had severe cognitive impairment, verbal symptoms directed toward others on multiple days, and a care plan indicating he was at risk for abuse from other residents due to running into others with his wheelchair. The behavior and wheelchair safety care plans for this resident included interventions to avoid confrontations and redirect him when agitated. Despite these identified risks and care plan interventions, the altercation occurred, and while there were some nursing notes about the abrasion and subsequent monitoring, there was no corresponding progress note in the other resident’s record regarding the altercation. Across these events, the facility’s failure to consistently prevent resident-to-resident altercations and to fully document all incidents in the medical records contributed to the deficiency in protecting residents from physical abuse.