Crestmoor Care Center: Resident-on-Resident Assault - CO
That is what federal inspectors documented when they visited Crestmoor Care Center, at 895 South Monaco Parkway, on February 6, 2025.
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See the Derila PillowThe resident who was hit, identified in inspection records as Resident #69, was over 65 years old and living with dementia and depression. She was almost entirely dependent on staff for daily care. Her January 2025 cognitive assessment gave her a BIMS score of zero out of fifteen, meaning she had essentially no measurable ability to process or communicate what was happening around her. Staff who knew her told inspectors she never initiated contact with other residents. Other residents would grab onto her or follow her. She did not reach out to them.
The resident who struck her, Resident #235, had a documented pattern of behavioral episodes going back months. A progress note from March 12, 2024, recorded that Resident #235 had been yelling at other residents in the hallway that evening, and nursing staff had to intervene to separate her from them. That was roughly the same period when the dining room incident took place.
The nursing home administrator described what happened in an interview with inspectors on the evening of February 6. He said the two residents got into a scuffle over seating in the dining room in March 2024. He said he did not believe Resident #235 was trying to hurt Resident #69, but acknowledged she hit her in the face. He explained that two residents had both been trying to befriend a third resident and all of them wanted to sit in the same specific chair. The facility removed that chair, he said, and the problem went away.
He did not describe any reassessment of how Resident #235 and Resident #69 were supervised together after the incident. He did not describe any change to Resident #235's care plan to address the behavior that led to the assault. He did not describe any additional protective measures put in place for Resident #69, a woman with no cognitive capacity to recognize danger or ask for help.
A certified nursing assistant interviewed the same afternoon said Resident #69 had no issues with any other residents, that other residents were the ones initiating contact with her, not the other way around. The picture that emerges from the staff interviews is of a woman who could not protect herself, surrounded by residents whose behavior toward her was unpredictable, cared for by a facility that responded to her being punched in the face by removing a piece of furniture.
Inspectors cited the facility for failing to protect residents from neglect and from resident-to-resident abuse. The level of harm was recorded as minimal harm or potential for actual harm. Few residents were identified as affected.
The administrator's explanation, stripped of its framing, is that the intervention worked because there were no further reported incidents. What it does not account for is the incident that did happen, to a woman who scored zero on a cognitive test and depended on staff for nearly everything, and whose only protection after being hit in the face was that the chair she had been sitting in was no longer there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crestmoor Care Center from 2025-02-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 14, 2026 · Our methodology
CRESTMOOR CARE CENTER in DENVER, CO was cited for violations during a health inspection on February 6, 2025.
That is what federal inspectors documented when they visited Crestmoor Care Center, at 895 South Monaco Parkway, on February 6, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.