Forest Ridge Health: Resident Assault, Missing Records - CO

The August 16 assault at Forest Ridge Health and Rehab LLC left one resident with red marks on his arm and sent his attacker to the emergency room for psychological evaluation. The assailant never returned to the facility.

Federal inspectors found no documentation of the incident in the medical records of either resident involved.

Staff discovered the fight when they couldn't open a door to one of the rooms. Two residents were pressed against it from inside. A registered nurse told both men to let each other go, and seconds later staff were able to enter.

They found Resident #1 with his hands on Resident #3's neck. Resident #3 had grabbed Resident #1's shirt. A certified nurse aide separated them while a registered nurse and another aide witnessed the altercation.

Resident #1 was placed under one-to-one supervision until emergency medical services arrived. Resident #3, the victim, showed red marks on his left forearm when staff assessed him afterward.

When interviewed by the facility's Social Services Director, Resident #3 said he wanted other residents to stay out of his room.

The facility's investigation concluded that abuse had occurred.

Resident #3 was 83 years old and had been admitted earlier in 2025. His September care plan documented multiple forms of dementia, including unspecified moderate dementia with agitation and mild neurocognitive disorder with behavioral disturbance. He also had recurrent depressive disorder and anxiety.

A May assessment revealed severe cognitive impairments. His brief interview for mental status score was two out of 15 points.

Despite these documented vulnerabilities and the witnessed assault that left physical marks, inspectors found no record of the August 16 incident anywhere in Resident #3's medical files.

The attacker's records were equally blank. Resident #1's medical files contained no documentation about the physical abuse incident either.

Staff interviews revealed systemic problems with monitoring residents prone to wandering and aggression. The facility operated a secured unit where both residents lived, but supervision appeared inadequate for the behaviors staff described.

CNA #1 had worked on the secured unit since June 2025. She told inspectors that Resident #1 "often wandered" and that staff "needed to keep an extra set of eyes on him during their shifts and redirect him often."

The aide said Resident #1 "usually disregarded the stop banners across doors and he ducked under them." These banners were meant to prevent residents from entering rooms where they weren't welcome.

The unit operated with two certified nurse aides and one registered nurse for both hallways during each shift. Staff divided the unit among themselves to monitor residents, with cameras at the nurses' station providing views of all resident doors simultaneously.

Yet this surveillance system failed to prevent the assault.

CNA #1 said she didn't work the day of the incident between the two residents. She described Resident #3 as protective of his space, keeping his door closed most of the time. He had a stop sign banner across his door, but kept it "above head level."

The positioning rendered the warning ineffective against someone like Resident #1, who ducked under such barriers.

Another aide, CNA #2, said a nurse had informed her that Resident #1 often wandered. This suggests staff awareness of his behavioral patterns, yet no effective intervention prevented him from entering another resident's room and initiating physical contact.

The facility had previously moved a different resident, Resident #2, to the second floor to address similar room-entry issues. LPN #1 described this relocation as successful, saying the second floor provided "a more relaxed environment" with "more cognitively intact" residents who "understood that they were not to enter other residents' rooms."

This solution worked for Resident #2, who "started interacting with others and did not exhibit any behavioral problems" after the move. There were "no incidents when other residents attempted to enter Resident #2's room since he had moved to the second floor."

The second floor had "no residents with wandering behaviors," according to LPN #1.

Yet the facility apparently made no similar accommodation for Resident #1, despite staff knowledge of his wandering patterns and tendency to ignore room barriers.

The documentation failures extended beyond missing incident reports. The facility's investigation concluded abuse had occurred, but this finding appears nowhere in the medical records that would follow these residents through any future care transitions.

For Resident #3, the absence of documentation means future caregivers would have no record of his victimization or the physical injuries he sustained. They would be unaware that he had been strangled by another resident and had specifically requested that others stay out of his room.

For Resident #1, the missing documentation conceals his history of physical aggression toward vulnerable residents. Any future facility accepting his care would lack crucial information about his propensity for violence and the circumstances that led to his psychiatric emergency.

The inspection occurred during a complaint investigation on September 8, 2025. Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting some residents.

The federal citation fell under tag F 0600, which addresses the facility's responsibility to ensure residents are free from abuse and the facility must not employ individuals who could abuse residents.

Resident #3 remains at Forest Ridge Health and Rehab, living with severe cognitive impairments in a secured unit where documentation failures have erased the record of his assault.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Forest Ridge Health and Rehab LLC from 2025-09-08 including all violations, facility responses, and corrective action plans.

Additional Resources

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