The assistant administrator told federal inspectors that only one resident witnessed the slapping incident between resident #1 and resident #2. When staff interviewed resident #1, the person could not remember being hit.
Based on those factors, the assistant administrator said the facility determined the incident was "not reportable." She explained that when an incident wasn't witnessed by staff, the facility would investigate first and then decide whether it needed to be reported to authorities.
The facility's own policy contradicts that approach.
Handmaker Home's written procedures on abuse, neglect and exploitation, dated July 2025, state the facility must report "all alleged violations" to multiple agencies within specific timeframes. Incidents that don't involve serious bodily injury must be reported within 24 hours.
The policy requires immediate notification to the administrator, state agency, adult protective services, law enforcement when applicable, the ombudsman, and residents' families. The administrator must then follow up during business hours to confirm reports were received and provide investigation results within five working days.
The assistant administrator told inspectors she was aware of the September 3 incident but denied receiving any allegations of verbal abuse related to resident #1 before the slapping occurred. She said the slapping was the only incident between residents #1 and #2 that the facility knew about.
According to the assistant administrator, staff are supposed to report any witnessed abuse or suspected abuse to their direct supervisor, who would then report the allegation to her. She would notify the administrator, staff #110, and together they would report the allegation and complete a five-day investigation to the state agency.
They would also report to local police, Adult Protective Services, the ombudsman, and residents' families, she said.
But none of that happened with the September 3 slapping incident.
The facility's interpretation of its reporting requirements appears to hinge on whether staff directly witnessed an incident. The assistant administrator suggested that incidents without staff witnesses require internal investigation before external reporting.
However, the written policy makes no such distinction. It requires reporting of "all alleged violations" within the specified timeframes, regardless of who witnessed them.
The policy also mandates immediate reporting, "no later than 2 hours after the allegation is made" if events involve abuse or result in serious bodily injury. For incidents that don't involve abuse and don't result in serious bodily injury, the deadline extends to 24 hours.
A resident-on-resident slapping incident would typically fall under the 24-hour reporting requirement.
The assistant administrator's statement that the facility investigates first and then decides whether to report suggests a process that could delay or prevent required notifications to protective agencies.
Federal regulations require nursing homes to immediately report suspected abuse to the administrator and notify appropriate authorities within 24 hours. The regulations don't provide exceptions for incidents without staff witnesses or cases where victims can't remember what happened.
Resident #3 witnessed the slapping incident, according to the inspection report. The fact that another resident saw the incident occur would typically constitute sufficient evidence for reporting purposes under federal guidelines.
Memory issues among nursing home residents, particularly those with dementia or cognitive impairment, are common. Resident #1's inability to remember being hit doesn't negate the witness account or eliminate reporting obligations.
The assistant administrator's description of the facility's usual reporting process suggests staff understand the proper procedures. She outlined the chain of command for reporting suspected abuse and listed the multiple agencies that should receive notifications.
But the September 3 incident reveals a gap between policy and practice.
The facility determined the slapping wasn't reportable despite having a witness and written procedures requiring notification of all alleged violations. The decision appears to rest on the victim's memory loss and the absence of staff witnesses rather than the severity or nature of the incident itself.
Adult Protective Services, law enforcement, the state agency, and the ombudsman never learned about the September 3 slapping because Handmaker Home decided internally that the incident didn't meet reporting thresholds.
Families of the residents involved also weren't notified, according to the inspection findings.
The facility's policy acknowledges different timeframes based on incident severity. Incidents involving abuse or serious bodily injury require reporting within two hours. Other incidents must be reported within 24 hours.
A slapping incident between residents would likely qualify for the 24-hour reporting requirement, even if it didn't cause serious bodily injury.
The assistant administrator's statement that she wasn't aware of prior verbal abuse allegations related to resident #1 suggests the September 3 incident was treated as an isolated occurrence. However, patterns of aggressive behavior between residents often escalate without intervention.
Early reporting allows protective agencies to assess situations and provide resources before incidents become more serious. Delayed or absent reporting can leave vulnerable residents at continued risk.
The inspection found the facility's approach to reporting violated federal requirements for immediate notification of suspected abuse. Handmaker Home's internal decision-making process effectively substituted facility judgment for regulatory mandates and protective agency oversight.
Resident #1 remains at the facility, along with resident #2 and the witness, resident #3. The September 3 slapping incident was never reported to authorities responsible for investigating abuse in long-term care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Handmaker Home For the Aging from 2025-09-12 including all violations, facility responses, and corrective action plans.