FORT COLLINS, CO - Columbine West Health & Rehab Facility faces immediate jeopardy citations from federal inspectors after failing to protect residents from sexual abuse, resulting in one female resident being assaulted by a male resident with a documented history of inappropriate behavior.
Sexual Assault Incident Reveals Systematic Failures
On February 5, 2025, a staff member witnessed Resident #2, a male patient with severe dementia, grabbing the breast of Resident #1, an 81-year-old woman with Alzheimer's disease. When told to stop, Resident #2 reportedly said, "She likes it." The incident occurred in the facility's secured dementia unit, where both residents lived.
The assault was particularly troubling because Resident #2 had a documented history of sexually inappropriate behavior toward staff and female residents dating back to November 2022. His care plan specifically noted "inappropriate comments evidenced by making sexual or rude comments about people's physical appearance."
Despite this known history, facility records show that many staff members were unaware of Resident #2's behavioral issues and the specific interventions required to protect other residents.
Staff Unaware of Critical Safety Protocols
Federal inspectors found that multiple staff members working in the secured unit had no knowledge of Resident #2's sexually inappropriate behavior or the safety measures needed to prevent incidents. During interviews conducted on February 25, 2025:
- CNA #4, who worked on the secured unit, stated she was "unaware of any sexual situation that had happened between Resident #1 and #2 and was unaware of any behavior monitoring for Resident #2."
- CNA #3 said she "was unaware of any sexually inappropriate incident between Residents #1 and #2."
This lack of awareness created dangerous conditions where vulnerable residents remained at risk despite documented safety concerns.
Pattern of Inadequate Response to Sexual Behavior
The facility's response pattern revealed multiple concerning issues. Following the February 5 incident, administrators implemented one-to-one supervision for Resident #2 until his medical provider could assess him. However, this supervision was lifted on February 7 at 9:30 a.m. after a medication change, even though the facility lacked proper monitoring systems to ensure staff awareness of ongoing risks.
Behavior monitoring for both residents was initiated after the incident but discontinued on February 19 without documented justification for ending the oversight. Records contained no evidence of discussions about why monitoring ceased or what factors influenced this decision.
Second Resident Poses Similar Risks
The investigation uncovered another concerning pattern involving Resident #4, who had a documented history of sexual behavior toward female staff. On August 8, 2024, this resident was observed "rubbing Resident #3's left breast." His care plan, initiated that same day, specified he should "sit next to other male residents in group settings to mitigate risk of inappropriate expressions towards other residents."
Despite these clear instructions, inspectors observed Resident #4 sitting at the nurses' station within arm's reach of a female resident on February 26, 2025. Staff interviews revealed they were unaware of his inappropriate behavior history and the required seating interventions.
Medical and Safety Protocol Failures
The facility's approach to managing sexually inappropriate behavior violated established medical protocols for dementia care. When residents with cognitive impairment exhibit sexual behaviors, facilities must implement comprehensive monitoring, staff education, and environmental modifications to ensure safety.
Proper dementia care requires consistent application of person-centered approaches that account for each resident's specific behavioral patterns. This includes ensuring all staff understand individual risk factors and intervention strategies, particularly in secured units where vulnerable residents have limited ability to protect themselves.
The medication prescribed for Resident #2 - methimazole for "agitation and hypersexual behaviors" - required careful monitoring for effectiveness. However, records showed no systematic tracking of behavioral changes or medication response, representing another breakdown in clinical oversight.
Facility's Immediate Response Plan
When notified of the immediate jeopardy determination on February 26 at 2:45 p.m., facility administrators submitted a correction plan by February 27 at 10:18 a.m. The plan included:
- Assigning one-to-one staff supervision for Resident #2 through February 27, followed by additional staffing on all shifts for the secured unit - Immediate education for all current and incoming staff about sexually inappropriate behaviors and required interventions - Implementation of a shift-to-shift communication system emphasizing behavioral concerns - Review of all residents with documented sexual behavioral issues within the past six months
The nursing home administrator confirmed that comprehensive staff education was completed by February 27, with multiple employees demonstrating understanding of new protocols during follow-up interviews.
Industry Standards for Abuse Prevention
Federal regulations require nursing homes to maintain comprehensive abuse prevention programs that protect residents from all forms of harm, including resident-to-resident incidents. Facilities must conduct thorough behavioral assessments, implement appropriate interventions, and ensure all staff understand specific safety protocols for each resident.
For residents with dementia who exhibit sexually inappropriate behaviors, evidence-based practices include environmental modifications, consistent staffing assignments, and regular behavioral monitoring. Staff education must be ongoing and include specific intervention techniques for redirecting inappropriate behavior while maintaining resident dignity.
Consequences and Ongoing Monitoring
The immediate jeopardy citation was removed on February 27 at 3:20 p.m. after facility administrators demonstrated implementation of their correction plan. However, deficient practices remained at a level indicating "a pattern with the potential for more than minimal harm."
Federal inspectors will continue monitoring the facility's compliance with abuse prevention requirements. The citation represents serious regulatory violations that could impact the facility's Medicare and Medicaid certification if not properly addressed.
Families of current and potential residents should be aware of these violations when making care decisions. The facility's failure to maintain basic safety protocols in a secured dementia unit raises questions about overall care quality and resident protection measures.
The incident highlights the critical importance of comprehensive staff training and communication systems in nursing homes, particularly for facilities serving residents with cognitive impairments who cannot advocate for themselves or report concerning behaviors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Columbine West Health & Rehab Facility from 2025-02-27 including all violations, facility responses, and corrective action plans.
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