The September 27 altercation began when Resident #1 became agitated while sitting at the smoking doors around 11:30 AM, yelling at staff to "let me out of this f***ing place, I want to go back to council bluffs," according to a progress note written that afternoon.
When a certified nursing assistant tried to push the resident's wheelchair, he grabbed her hand and ripped off her fingernail. The resident began laughing and continued talking to himself as he pushed his wheelchair to the nurses station.
That's where he encountered Resident #2.
Both men started yelling and cursing at each other between the dining area and nurses station. Then both stood up from their wheelchairs. Resident #1 stepped forward and struck Resident #2 in the face with a closed fist before a nurse and nursing assistant separated them.
Neither resident was seriously injured. Resident #2 denied pain and showed no new skin concerns from being hit, staff noted.
But federal inspectors who visited Oakland Manor on October 15 discovered that nearly three weeks later, neither resident's care plan had been updated to address what happened or prevent future incidents.
Both residents have cognitive impairments that likely contributed to the confrontation. Resident #1 scored 10 on a mental status assessment, indicating mild cognitive impairment, and has diagnoses of dementia, schizophrenia and post-traumatic stress disorder. Resident #2 scored 6 on the same assessment and has metabolic encephalopathy, a brain condition often caused by kidney problems.
When inspectors asked who should have updated the care plans after the altercation, the facility's MDS coordinator said it would have been "the nurse in charge that day or whomever was doing the reportable incident report." She wasn't working the weekend the fight occurred but thought the care plans had been updated.
They hadn't been.
The administrator acknowledged both residents' care plans should have been revised to reflect the September 27 incident. She said the plans should have included "interventions to keep the residents safe, any medications that were adjusted and interventions to prevent this from happening again."
Federal regulations require nursing homes to develop complete care plans within seven days of assessing residents and to update those plans when residents' conditions or circumstances change. The care plans are supposed to be prepared, reviewed and revised by a team of health professionals.
Oakland Manor's own policy, last reviewed in 2019, states that each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that will guide how staff provide care.
The facility houses 40 residents.
The failure to update care plans after the altercation left both residents without specific interventions designed to prevent similar incidents. For Resident #1, whose agitation led to violence, the missing updates meant no documented strategies for managing his outbursts or keeping him away from situations that might trigger aggressive behavior.
For Resident #2, the victim of the punch, the unchanged care plan provided no additional protections or environmental modifications that might keep him safe from future attacks.
The incident highlights how documentation failures can perpetuate safety risks in nursing homes. When staff don't update care plans after significant events like resident-to-resident altercations, they miss opportunities to identify patterns, implement preventive measures, and ensure all caregivers understand each resident's specific triggers and needs.
The MDS coordinator's assumption that someone else had handled the care plan updates underscores the confusion about responsibilities that can occur when facilities don't have clear protocols for responding to incidents involving multiple residents.
Three weeks after the fight, both men remained at Oakland Manor with the same care plans they had before one punched the other in the face.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakland Manor from 2025-10-15 including all violations, facility responses, and corrective action plans.