The August incident at Creekside Village Rehabilitation and Nursing was the second sexual abuse case in two months involving residents with cognitive impairment. Federal inspectors who visited in September found the facility had substantiated both incidents as abuse but failed to implement adequate protections.
Resident #3 had a documented history of sexually inappropriate behaviors because she confused male residents with her husband, according to certified nurse aide interviews. Staff knew she needed supervision to prevent her from getting too close to male residents in public areas and from wandering into other residents' rooms.
On August 19, staff entered the dining area and found Resident #3 sitting in her wheelchair with her hands down the front of Resident #4's pants while he stood nearby. Staff immediately separated the residents. Neither could recall the incident due to cognitive impairment, and no injuries were found during assessments.
The nursing home administrator told inspectors that abuse was substantiated in the incident. The interdisciplinary team met afterward, contacted families, and claimed to look for appropriate solutions to prevent further abuse.
But those solutions proved inadequate.
During the September 4 inspection, federal investigators observed Resident #3 entering the rooms of two male residents and lying on one man's bed. When asked where the resident was after she left the dining room that day, registered nurse #1 said she didn't know. The nurse eventually found Resident #3 in a room that wasn't hers and helped her back to her own room for a nap.
"Resident #3 was very fast and the staff tried to keep an eye on her," the nurse told inspectors. She acknowledged that the resident occasionally had sexually inappropriate behaviors, touching male residents because she thought they were her husband. Staff were supposed to ensure she didn't enter other residents' personal space.
The observation revealed the interventions weren't working.
A second abuse incident had occurred two months earlier involving different residents. On June 16, Resident #2 and Resident #1 were involved in what the administrator described as a substantiated abuse case. Certified nurse aide #3 explained that Resident #2 was sensitive about his personal space, and staff were trying to keep wandering residents like Resident #1 away from him.
The aide said interventions after that incident focused on keeping the residents separated and redirecting them when necessary.
Resident #3's severe cognitive impairment was documented in a June 20 assessment that showed a BIMS score of zero out of 15. The assessment indicated she didn't have physical behaviors toward others, but staff interviews revealed a pattern of sexual inappropriateness that the facility had failed to adequately address.
The director of nursing acknowledged awareness of both incidents during her September 4 interview. She said staff received additional education after the August incident on preventing and de-escalating physical altercations and ensuring residents didn't enter each other's personal space.
She promised more education specifically about Resident #3 to prevent her from entering other residents' rooms by mistake. The memory care unit used colored doors to help residents remember their own rooms, and the director said staff would consider other options to help Resident #3 locate her room more easily.
The nursing home administrator emphasized that the facility's goal was keeping all residents free from abuse and ensuring appropriate interventions for residents with behavioral issues. He said both incidents were investigated and reported in a timely manner, with the interdisciplinary team meeting after each case.
But the September observations showed Resident #3 continued wandering into inappropriate areas despite the promised interventions. The registered nurse's inability to locate the resident and the observation of her in another resident's bed demonstrated ongoing supervision failures.
Certified nurse aide #3 described the challenge of monitoring Resident #3's movements, saying staff did their best to keep wandering residents away from those sensitive about personal space. The aide confirmed that Resident #4, the victim in the August incident, was not physically aggressive and had no history of inappropriate behaviors himself.
The facility's response to the pattern of incidents focused on education and environmental modifications like colored doors. However, the continued wandering and inappropriate room entries observed during the inspection suggested these measures were insufficient for a resident described as "very fast" who regularly confused other residents with her husband.
Federal inspectors classified the violations as minimal harm with potential for actual harm, affecting few residents. The findings revealed a facility aware of specific risks but unable to implement effective protections for vulnerable residents with severe cognitive impairment.
The August dining room incident occurred in a public area where staff supervision should have been routine. The fact that Resident #3 was able to inappropriately touch another resident while both were in the dining area raised questions about staffing levels and attentiveness during meal times and social activities.
Resident #4's standing position during the incident suggested he may not have understood what was happening or been able to protect himself, highlighting the vulnerability of residents with cognitive impairment to abuse by other residents with similar conditions.
The facility's acknowledgment that both incidents constituted substantiated abuse cases demonstrated recognition of the seriousness of the violations. However, the continued observations of inappropriate behavior during the federal inspection indicated that recognition alone was insufficient to protect residents.
The nursing home's promise to consider additional options for helping Resident #3 locate her room came only after federal inspectors observed her continuing to enter inappropriate areas. The reactive rather than proactive approach to resident safety left vulnerable individuals at ongoing risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Creekside Village Rehabilitation and Nursing LLC from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Creekside Village Rehabilitation and Nursing LLC
- Browse all CO nursing home inspections