By Jordan Rau, KFF Health News
Sam Ato Timaloa, a paroled sex offender who also served time for attempted murder, had dementia and an acute intolerance of noise — especially from roommates at Sunrise Post Acute, a nursing home in Banning, California. Over four months in 2025, a state investigative report found, Sunrise switched Timaloa’s room eight times, the last into one occupied by Attilio Cecchetto, 92, a retired tile installer whose dementia led him to frequently moan, mumble, and yell.
Overnight, a nurse aide walked into their room and saw blood splattered on the floor, walls, and ceiling, according to a grand jury transcript. Cecchetto’s face “looked twisted and smashed,” the aide testified. A Banning city police officer testified that Timaloa, 77, told him that he had punched Cecchetto twice.
Cecchetto died two days later from blunt force facial trauma. “You get placed in a facility like this to be taken care of, not to be murdered,” one of his sons, Gino Cecchetto, said in an interview. “This was completely preventable at many different points.”
In nursing homes primarily occupied by impoverished people as well as posh assisted living facilities that cost upward of $10,000 a month, agitated residents have shoved, punched, bit, and kicked others. They have wielded canes, walkers, pens, a plate, a mop stick, a shoe, a belt buckle, and even the footrests of wheelchairs as weapons, federal inspection reports show.
How often these altercations take place nationwide is unknown, but an in-depth study of 14 assisted living facilities in New York state led by Cornell University researchers estimated 1 in 7 residents experienced aggression within a month, including verbal, physical, or sexual acts. A separate study of 10 New York state nursing homes estimated 1 in 5 residents experienced an altercation in a month. Researchers have found that these assailants are disproportionately likely to have dementia.
Often, altercations involving a resident with dementia erupt after danger signals are missed or ineffectively addressed, according to a KFF Health News examination of court records, police reports, and state and federal inspection reports.
Since the start of 2024, the federal Centers for Medicare & Medicaid Services has faulted nursing homes at least 700 times for failing to protect residents from physical, sexual, or verbal abuse by other residents, CMS inspection reports show. In the first three months of this year, CMS cited nursing homes more often for resident-to-resident abuse than for any other type of abuse, neglect, or exploitation, including abuse by employees.
Eilon Caspi, a dementia consultant and researcher who studies resident-on-resident altercations, said that usually there is a specific unmet need that precedes an altercation. “In the vast majority of incidents,” he said, “there are warning signs in the months, weeks, days, hours, and sometimes minutes and seconds prior.”
Fertile Battlegrounds
As cognition clouds, people lose the ability to understand what is happening around them and to put distress into words, researchers say. Pain, infection, medication side effects, and other physical and emotional distresses may be expressed through shouting, intimidating gestures, kicking, pushing, or punching. Long-term care facilities can be triggering environments, with intimate care often delivered by a changing stream of aides whom residents can’t recognize.
“You don’t feel safe, because you don’t know these strangers who are coming in and taking off your clothes,” said Al Power, a geriatrician and an advocate for alternative models of care for people with cognitive issues. “These things will be distressing to anybody.”
Laura Mosqueda, a geriatrician at the University of Southern California’s Keck Medicine in Los Angeles and a senior adviser to the National Center on Elder Abuse, said: “What worries me is that we just end up blaming two people who have either cognitive impairment or severe, uncontrolled mental health issues, when they’re supposed to be in an environment where people are safe.”
‘Only a Matter of Time’
Gladys Lynch, a retired department store accountant, transferred into the memory care unit at Harbor Crossing in White Bear Lake, Minnesota, in September 2025. One of Lynch’s daughters, Rebecca Norton, installed web cameras in her room and often saw another resident inside, “harassing her, digging through her things, using her bathroom, yelling at her,” Norton said in an interview.
Unknown to Norton, Harbor aides had raised concerns about the other resident, who was also new to Harbor Crossing’s memory unit, according to a Minnesota Department of Health report. Diagnosed with Alzheimer’s, severe dementia with agitation, depression, and anxiety, the woman was confused, had difficulty communicating her needs, and hit aides. One nurse told the woman’s doctor it was “only a matter of time before” she “hurts another resident.”
On the last day of September, the woman entered Lynch’s room and resisted leaving, the state report said. The next morning she reappeared, declared it was her house, and used Lynch’s bathroom. Video reviewed by KFF Health News shows Lynch repeatedly pressing an alert pendant to signal nurses for help. The woman pushed Lynch, who fell, her head hitting the floor. Aides arrived 13 minutes after Lynch first pressed her pendant. Lynch suffered a brain hemorrhage and fractures to her eye socket and ribs, and died in the hospital five days later at age 96; the medical examiner’s office declared it a homicide.
Prosecutors declined to bring charges. The state investigation concluded Harbor Crossing was responsible for neglect because it was aware the woman “exhibited violent and aggressive behaviors” and yet had failed to put in place effective interventions. Harbor Crossing has requested the state reconsider its findings. In June, the attorney for Lynch’s family filed a wrongful death lawsuit against Presbyterian Homes, which owns Harbor Crossing.
Preventive Tactics
Geriatricians, researchers, and resident advocates say long-term care homes should employ strategies to reduce the risk of altercations, including closer supervision of residents at high risk, relocating them closer to nursing stations, separating residents with repeated conflicts, and adjusting roommate assignments or seating in shared spaces. Each resident should have a care plan, and homes should train staff to be alert to a resident’s triggers and intervene quickly. Organized activities are essential to keep residents occupied and engaged.
An aide can be assigned to watch a particularly challenging resident one-on-one, but many places lack enough staff for protracted, dedicated supervision. Camille Russell, who served as Kansas’ long-term care ombudsman until 2024, said she observed nurses and aides were often “woefully undertrained” in basic elements of dementia care. “We’ve gotten too far away from making decisions that are caring decisions,” Russell said. “There has to be a balance, and the balance has gotten too far to the profit side.”
A Debilitating Kick
Linda Twiddy’s first weeks in a Chesapeake, Virginia, memory care unit in August 2024 were happy, her daughter, Barbara Howerin, said. Seven weeks after Twiddy started living there, a nurse called Howerin to say her mother had been kicked in an altercation with another resident and was being sent to the hospital. “It was like 10 inches long by 6 inches wide, the whole front of her shin,” Howerin said. “The calf was just like dangling down.”
According to an internal facility incident report the family obtained, an aide heard Twiddy scream for help and found a male resident with dementia trying to hit Twiddy as she sat on the floor in “a pool of blood.” The man had prior episodes of aggression, according to documents obtained in a lawsuit the family brought against the facility, The Vero at Chesapeake, in Chesapeake Circuit Court. In a court filing, The Vero denied allegations that it should have protected residents from him. Virginia regulators alleged The Vero had failed to assume responsibility for the health, safety, and well-being of its residents.
Twiddy underwent three surgeries at the hospital for her leg, including a skin graft, then spent a month in rehabilitation. “She was never able to walk again,” her son, Doug Twiddy, said. The lawsuit was settled on confidential terms in early June.
A History of Violence
After Attilio Cecchetto was fatally bludgeoned at Sunrise Post Acute, his adult children and their attorney discovered disturbing details about Sam Ato Timaloa. He had been imprisoned in 1999 after being convicted of raping an underage girl and sentenced in 2008 to 24 years in prison for attempted murder involving domestic violence, according to Riverside County court records.
Cecchetto’s sons also learned more about the home’s owner, PACS Group, a publicly traded company with more than 300 long-term care facilities that earned $191 million on revenue of $5.3 billion last year, according to its annual securities filing. In the lawsuit the Cecchettos and their father’s widow filed against PACS, they accused the company’s founders of draining resources from their nursing homes to pay for the chain’s expansion and swell their personal wealth. The two had earned more than $650 million through stock sales since taking the company public and bought two private luxury jets, according to the lawsuit and securities filings.
California regulators fined Sunrise $120,000 for failing to protect Cecchetto and for not taking Timaloa’s articulated dislike of noise into account when assigning rooms. Medicare issued its own $62,810 fine. In legal papers responding to the Cecchettos’ lawsuit, PACS denied negligence for his death and alleged he “failed to exercise ordinary care on his own behalf for his own safety.” It has sued to overturn the $120,000 state fine.
The Cecchettos’ lawsuit asks for a judge to impose robust procedures PACS homes must follow for admissions, staff training, room changes, and the reporting of altercations between residents, and for a court-appointed monitor to oversee compliance.
“We don’t want this to happen to somebody again,” Gino Cecchetto said. “With the life he led, he deserved a quiet, dignified death. Instead, he ended his life in pain and fear.”
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