The incident at Ingleside Manor involved two residents in December 2024. One reported being backhanded in the face by another resident who then rammed her wheelchair into hers. But when administrators investigated the allegation, they interviewed seven nursing aides and three registered nurses — none of whom were working the shift when it happened.
The resident who reported the assault, identified in state records as R1, has metabolic encephalopathy, a condition that can disturb brain function. She scored 10 out of 15 on a cognitive assessment, indicating moderately impaired cognition. The other resident, R2, has dementia and anxiety and scored just two out of 15, indicating severely impaired cognition.
On December 19, 2024, around 7:30 PM, R1 was trying to exit her room in her wheelchair when R2 approached and yelled at her. R1 later told investigators that R2 shouted "Your children are [NAME]" along with other comments she couldn't recall. When R1 told R2 to get away from her, R2 backhanded R1 in the mouth, according to R1's account.
R2 then rammed her wheelchair into R1's wheelchair as R1 moved away.
R1 reported the incident to the registered nurse on duty, who spoke to R2 about it. The next day, R1's family member emailed the facility about the incident, initially believing it involved a staff member rather than another resident.
The facility's own policy requires thorough investigations of all abuse allegations. Specifically, it mandates that investigators interview "staff members (on all shifts) who have had contact with the resident during the period of the alleged incident" and document everything "completely and thoroughly."
But the investigation fell short of those standards.
During interviews conducted in December 2024, certified nurse aide CNA3 told the assistant administrator he hadn't witnessed the incident but heard CNA5 talking about it. More importantly, he said CNA4 had seen what happened.
CNA5 confirmed she hadn't witnessed R2 swing at R1, but mentioned that R2 had swung at both her and CNA4 the evening before the reported incident.
The assistant administrator sent an email to the former administrator on December 20, 2024, noting that CNA4 was an agency staff member and providing her phone number. The email stated: "if you would like to reach out."
Nobody did.
When federal inspectors interviewed CNA4 in March 2025, she provided crucial details about what actually happened. She recalled the two residents having a verbal altercation on December 19, 2024, and said they were separated. Later, R1 told CNA4 that R2 had "bopped her in the mouth," and CNA4 immediately reported it to the nurse.
CNA4 also provided context about R2's behavior patterns, saying R2 had a history of wandering and being combative with staff who tried to redirect her.
Most significantly, CNA4 told inspectors that no one from the facility had ever contacted her about the incident.
The assistant administrator admitted to inspectors in March 2025 that she couldn't verify whether CNA4 had been contacted during the original investigation. When pressed further, she acknowledged the investigation wasn't thorough.
"She would have reached out to everyone on the schedule that shift as well as previous shifts, to find out more about what may have escalated any behaviors," the inspection report noted.
The facility's investigation also revealed concerning details about R2's behavior toward staff. CNA5 reported that R2 had swung at her and another aide the evening before the alleged assault on R1. CNA3 described R2 as someone who "went from really happy to really upset quickly for no known reason."
When inspectors interviewed the residents in March 2025, their accounts differed from the original reports. R2 smiled and said everyone at the facility was nice, claiming she had never hit anyone nor had anyone hit her.
R1's recollection had also changed. She remembered R2 ramming into the back of her wheelchair but couldn't recall if R2 had touched her. She did remember telling the nurse what happened and felt the nurse had addressed it because R2 "hasn't bothered me since."
R1's family member confirmed the original account, recalling that R1 had told her on December 19, 2024, that "a woman tried to get past her to use the phone and had backhanded her." The family member tried calling the facility but got no answer, so she sent an email instead.
The investigation's shortcomings extended beyond the failure to interview key witnesses. The assistant administrator told inspectors she was primarily overseeing a different part of the building at the time and wasn't really involved in the investigation beyond helping with two resident interviews and two staff interviews.
She couldn't verify that any other staff interviews were conducted beyond the ones she completed.
The facility submitted a state abuse report on December 20, 2024, noting that a head-to-toe skin assessment revealed no injuries and that R1 didn't report feeling unsafe. The report stated the investigation was ongoing, but the failure to contact the primary witness suggests it was never completed properly.
Federal regulations require nursing homes to thoroughly investigate all allegations of resident-to-resident abuse. The facility's own policy echoed this requirement, but the actual investigation fell far short of both federal standards and the facility's written procedures.
The incident highlights broader challenges in managing residents with cognitive impairments who may become aggressive. Both residents involved had documented cognitive issues that could affect their behavior and their ability to recall events accurately.
R1 continues to live at the facility, as does R2. The family member who originally reported the incident remains in regular contact with R1, calling each night to check on her condition and wellbeing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ingleside Manor from 2025-03-14 including all violations, facility responses, and corrective action plans.
