BRIGHTON, CO - Federal inspectors documented serious violations at Riverdale Post Acute following multiple resident safety incidents, including unreported sexual abuse, repeated falls with head injuries, and medication errors that put vulnerable residents at risk.
Multiple Physical Altercations Between Residents Go Unaddressed
The facility experienced a pattern of physical confrontations between residents with dementia that escalated without proper intervention. On February 8, 2025, a physical altercation occurred between two residents in a hallway near one resident's bedroom. During the incident, one resident attempted to hit another with his walker before physical contact was made between both parties.
Despite both residents having documented histories of aggressive behavior, care plans in place, and previous incidents, the facility's investigation concluded the altercation was "unsubstantiated as an act of abuse." However, federal inspectors determined that abuse had occurred because one resident attempted to use his walker as a weapon against another resident, who then retaliated with physical contact.
The incident involved Resident #34, a 71-year-old with dementia and behavioral disturbances who had a documented history of physical aggression toward staff and peers. His care plan specifically noted triggers including being approached from behind and having poor impulse control related to traumatic brain injury and PTSD. The other resident, Resident #97, was 85 years old with severe cognitive impairment who had a history of physical aggression and inadvertently running into others while walking.
A separate incident on March 10, 2025, involved another physical altercation where one resident "opened his bedroom door, quickly walked over to the dining room and started kicking" another resident who was watching television. Staff witnessed the assault, which required the aggressive resident to be transferred to the hospital emergency department after he could not be redirected and had to be restrained and sedated by emergency medical technicians.
These incidents highlight fundamental failures in managing residents with behavioral health needs and implementing effective intervention strategies to prevent resident-to-resident violence.
Sexual Abuse Incident Goes Unreported to State Authorities
In one of the most serious violations, the facility failed to report an incident of potential sexual abuse to state authorities as required by federal law. On March 21, 2025, between 1:30 and 2:00 a.m., a certified nursing aide discovered a male resident "halfway into" a shared room occupied by two female residents. The male resident had exposed his genitals and was masturbating while the female residents slept.
The facility's investigation revealed that this resident had a documented history of inappropriate sexual behavior, including making explicit comments to staff, masturbating in front of staff, and asking female staff members for inappropriate physical contact. Despite this pattern of behavior and a care plan addressing his hypersexual conduct, the facility had failed to implement adequate safeguards.
When questioned by federal inspectors, the nursing home administrator acknowledged that any allegations of abuse must be reported to the state agency within 24 hours. However, he stated that he had not reported this incident because a clinical consultant told him "the incident was not abuse." This decision directly violated federal reporting requirements and left the facility's most vulnerable residents at risk.
The failure to report sexual abuse represents a critical breakdown in resident protection protocols. Federal regulations require immediate reporting of suspected abuse to enable prompt investigation and implementation of protective measures. When facilities fail to report such incidents, residents remain exposed to ongoing harm and the broader long-term care system loses the opportunity to identify patterns of abuse across facilities.
Repeated Falls Result in Multiple Head Injuries
The facility's failure to implement effective fall prevention measures led to a resident experiencing five falls with head injuries over a two-month period. Resident #97, who had dementia, hearing impairment, and an unsteady gait, sustained falls on December 30, 2024, January 12, 2025, January 19, 2025, February 22, 2025, and February 24, 2025. Each fall resulted in head injuries requiring emergency department treatment.
The most serious incident occurred on February 22, 2025, when the resident fell and sustained a head laceration that resulted in a subarachnoid hemorrhage - bleeding between the brain and protective membranes. Two days later, while still having staples in his head from the previous fall, he fell again in the same area, requiring six additional sutures.
Despite having a fall prevention care plan that included interventions such as encouraging rest periods, ensuring appropriate footwear, and keeping the resident in line of sight, the facility failed to implement effective measures until after the third fall on January 22, 2025, when a soft helmet intervention was finally added. However, staff interviews revealed the resident was not wearing his protective helmet during the subsequent falls on February 22 and February 24.
Falls in nursing homes can have devastating consequences, particularly for residents with cognitive impairment who may not understand safety instructions or recognize hazards. Repeated head injuries in elderly residents can lead to permanent brain damage, increased confusion, and accelerated cognitive decline. The facility's delayed response to implementing additional safety measures after each successive fall with injury represents a failure to adapt care plans based on clear evidence of ongoing risk.
Medication Errors Compromise Patient Safety
During medication administration observations, inspectors documented a 6.06% error rate, exceeding the federal standard of 5%. In one incident, a licensed practical nurse administered omeprazole 20 mg instead of the prescribed 40 mg dose to a resident receiving medication through a feeding tube. The same nurse also placed a lidocaine patch on the wrong shoulder, contradicting the physician's specific order for left shoulder placement.
Medication errors in nursing homes can have serious consequences, particularly for residents with multiple chronic conditions who take numerous medications. Wrong dosages can lead to treatment failures, while incorrect placement of topical medications like lidocaine patches can result in inadequate pain relief and potential skin reactions at unintended sites.
Inadequate Care Plan Development Leaves Medical Needs Unaddressed
The facility failed to develop comprehensive care plans for residents with complex medical needs. One resident requiring supplemental oxygen and a PICC line for intravenous antibiotics had no care plan interventions addressing either medical device. The absence of proper care planning for oxygen therapy could result in inadequate monitoring of oxygen saturation levels and failure to recognize respiratory distress.
Similarly, two residents diagnosed with insomnia and prescribed sleep medications had no care plan interventions addressing their sleep disorders. Proper sleep hygiene interventions, environmental modifications, and monitoring for medication effectiveness are essential components of treating insomnia in elderly residents, whose sleep disruption can worsen cognitive function and increase fall risk.
Additional Issues Identified
Federal inspectors documented numerous other violations affecting resident care and safety. The facility failed to properly maintain medical devices, with one resident's PICC line dressing becoming visibly soiled without regular changes for over two weeks. Housekeeping and infection control failures included improper hand hygiene, failure to clean high-touch surfaces, and using the same toilet brush across multiple resident rooms.
Food service violations included serving mechanically altered diets that didn't match physician orders, potentially creating choking hazards for residents with swallowing difficulties. The facility also failed to obtain admission weights for residents with nutritional problems, missing critical baseline measurements needed for monitoring health status.
Building maintenance issues created an unsafe environment, with damaged flooring, water-stained ceilings, broken furniture, and bathroom fixtures in disrepair. These conditions can increase fall risks and create sanitation problems that threaten resident health.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverdale Post Acute from 2025-03-26 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.