Oakwood Care: Resident-on-Resident Attacks Unreported - CO

The incident was one of multiple unreported assaults at the facility, where federal inspectors found a pattern of resident-on-resident violence that administrators failed to properly investigate or report to the State Survey Agency.

On January 19 at 5:20 p.m., a certified nursing aide heard screaming from the room of Resident #2, a man with dementia and violent behavior diagnoses. Inside, staff found Resident #2 on the floor alongside Resident #1, a woman with early-onset Alzheimer's disease. Resident #1 had a large bruise and swelling around her left eye, blood coming from her mouth, and facial discoloration.

Resident #2 immediately admitted responsibility. "He said that he beat up Resident #1 because she wandered into his room," inspectors wrote.

But the attack wasn't surprising to anyone familiar with Resident #2's documented history of aggression toward other residents. For months, staff had recorded incident after incident of threatening behavior that escalated into physical violence.

On July 18, 2024, nursing notes documented that Resident #2 "approached multiple residents screaming and cursing at them for no reason." The next day, he was "calling residents names using explicit language" and "trying to physically trip other residents with his feet" while "stalking residents." Other residents were "fearful" during his overnight rampage.

Staff left a message for the director of nursing. Nobody reported potential abuse to administrators.

The pattern continued through the summer and fall. On August 13, Resident #2 "held a closed fist up to staff while swinging and yelling profanities" after being redirected from other residents' rooms. "Several residents got up and returned to their room, as they appeared afraid," nurses wrote. The facility called for emergency transport to evaluate him.

By August 16, he was "yelling profane names at the female residents as they walked by" and "kicking and banging on a resident's door, while yelling and cursing at the female resident on the other side of the door."

None of these incidents were reported to the nursing home administrator, who served as the facility's abuse coordinator.

The violence escalated in November. On November 3, Resident #2 physically assaulted Resident #8, another man with Alzheimer's disease. A physician's note documented that Resident #2 had "assaulted and punched his roommate," behavior the doctor noted the resident "had not had this type of behavior before."

The doctor was wrong. Previous documentation revealed months of profane and threatening language directed at other residents, plus the door-kicking incident where Resident #2 cursed at a female resident while she was in her room.

The December incident with Resident #24 showed how the facility mishandled investigations. On December 10 around 7:00 p.m., staff heard whimpering and a male voice yelling "Get out of here." They found Resident #2 standing over Resident #24, who was lying in a fetal position on a metal bed frame. Resident #24 had "visible fresh blood from his left eye area/eyebrow, as well as a skin tear to the top of his left hand."

Resident #2 told staff "he did not want this male resident in his room or to get in bed with him." He later said "he felt bad and was sorry, and that he was a nice person."

But administrators classified the incident as a fall, not an assault. When a physician examined Resident #24 the next day, the victim "was able to verbalize he was hurt by someone but denied being afraid." The doctor found lacerations on his eyebrow and hand.

Resident #2 told the physician: "I am not going to hurt anyone anymore" and said he was sorry.

Despite this clear admission of causing harm, the nursing home administrator said during interviews that both residents claimed there was no physical contact, so the facility "did not have reason to doubt that or they would have reported it."

The administrator and director of nursing blamed agency staff for poor documentation and failure to report incidents. They said some nursing notes weren't properly marked to appear in daily reports, making them harder to review and follow up on.

"The facility identified agency staff were working when Resident #2's behaviors were not accurately documented or reported," the regional clinical resource told inspectors.

After the January 19 attack, the facility implemented a plan to use only regular staff in the secure memory care unit instead of agency workers. Administrators said facility staff "knew the residents better" and could "better anticipate a resident's needs."

But the problems went deeper than staffing. Resident #2 was admitted in July 2024 with a documented history of violence. A provider note revealed he had "previously admitted to a hospital in April 2024 after assaulting an individual at a facility and being verbally abusive to the staff."

Despite this known history, the facility didn't create a behavioral care plan for verbal aggression until September 5 — nearly two months after admission. The physical behavior care plan wasn't implemented until November 4, after multiple incidents of threatening and aggressive conduct.

The care plans themselves were vague. Resident #2's verbal aggression plan noted he "acted in a playful way toward other residents which could be misconstrued," but never specified what these playful behaviors were or how they might be misconstrued as threatening.

Licensed practical nurse #3 told inspectors that Resident #2 was "easily redirectable" if staff said his name and asked him to "be a gentleman." The nurse said he never witnessed physical contact between Resident #2 and other residents, though he acknowledged the resident "verbally lashed out at other residents."

The facility placed a stop sign on Resident #2's door in November 2024 to discourage other residents from entering his room. But administrators weren't sure if Resident #1, who had severe dementia, could understand the warning sign.

Multiple residents suffered during Resident #2's months-long pattern of aggression. Federal inspectors found that the facility's failure to report incidents and implement effective interventions violated regulations designed to protect vulnerable residents from abuse and ensure they receive appropriate dementia care.

Resident #2 was ultimately discharged to a hospital after the January 19 attack on Resident #1.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Oakwood Care and Rehabilitation from 2025-01-29 including all violations, facility responses, and corrective action plans.

Additional Resources

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