Resident #6 at Altoona Nursing and Rehabilitation Center has moderately impaired cognition and diagnoses of dementia and diabetes, according to her assessment. Over nearly six months, she repeatedly targeted other residents trying to navigate the facility's dining room and lobby area.
The pattern began October 6, 2024, when staff noted Resident #6 had been "picking on another female resident" for two days. When the other resident's wheelchair blocked her path to her table, Resident #6 would shove the wheelchair to move her aside.
That day, she shoved the resident again and told her, "You dumb bitch, get out of my way."
Staff spoke with Resident #6 about treating the other resident appropriately, reminding her she couldn't put her hands on anyone or their wheelchair. Resident #6 responded: "Well you think she can get out of the way, what do you want me to do, go all the way around?"
Staff suggested she could walk around or ask the person to move.
The behavior continued. On March 22, 2025, Resident #6 became verbal toward another resident, telling them to "shut up" and "you don't belong here." She then pushed the other resident in their wheelchair into the table where they were sitting.
Again, staff reminded her the behavior was inappropriate and not to touch other residents or tell them to shut up.
A third incident occurred October 24, 2025, when Resident #6 hit another resident. Staff separated them but took no other action.
The facility's Director of Nursing told inspectors on October 29 that incident reports weren't filed for the October 6 and March 22 incidents "due to no one being hurt." For the October 24 hitting incident, she said the only intervention was separation because they couldn't remove Resident #6 from the dining room "because of her rights."
She admitted the facility didn't look at any other interventions.
Staff B, a Licensed Practical Nurse who witnessed the incidents, couldn't recall who the other residents were in either case. She didn't chart or follow up with the other residents involved and couldn't remember if the resident hit the table during the March incident.
"She did not fill out an incident report but if the resident would have been hurt she would have," Staff B told inspectors.
Staff B explained that Resident #6 is "possessive of her spot in the dining room/main lobby area" and "doesn't want anyone to sit at her spot ever."
Looking back, Staff B acknowledged she should have documented both incidents involving both residents.
The facility's own policy requires staff to investigate and report all accidents or incidents involving residents. The policy, dated July 2017, states that nurse supervisors and charge nurses must "promptly initiate and document investigation of the accident or incident."
Incident reports must include the date and time, circumstances, location, who was involved, the condition of those affected, corrective action taken, and follow-up information. The reports are supposed to be reviewed by the Safety Committee to identify trends and analyze individual resident vulnerabilities.
Federal inspectors found the facility failed to complete incident reports or proper documentation for two of the three resident-to-resident altercations they reviewed.
The inspection was conducted October 30, 2025, at the 97-bed facility in response to a complaint. Inspectors determined the violations caused minimal harm or potential for actual harm to a few residents.
The failure to document the incidents means the facility has no official record of the pattern of aggressive behavior, no analysis of what might prevent future incidents, and no tracking of whether other residents were affected by the confrontations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Altoona Nursing and Rehabilitation Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
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