The victim, identified in inspection records as Resident #2, told staff afterward: "I don't know why he just walked up and hit me."
But when state inspectors arrived in November following a complaint, they discovered the facility's administrator had conducted only a cursory review of the October 10 incident, dismissing it as potential abuse because no staff witnessed the initial contact between the two residents.
The incident began at 2:15 p.m. when staff heard cries for help coming from the dining room. When they arrived, they found Resident #2 on the floor with Resident #1 holding him down by the shoulders. The victim was "lying on the floor with his shoulders up-trying to release himself from the resident," according to the facility's incident report.
Staff immediately escorted the victim back to his room and notified the director of nursing and assistant director. The facility's psychiatric nurse practitioner was called and arrived to evaluate Resident #1, writing new orders for his care.
Neither resident could provide a clear account of what happened. Resident #1 was "unable to retell events of what occurred" and appeared calm after the incident. Both residents have severe cognitive impairments that left them unable to participate in interviews with state inspectors.
The facility's investigation, conducted by the previous administrator who also served as the abuse coordinator, concluded that staff "did not know what caused the incident, and there were no witnesses." The administrator noted that neither resident was injured and closed the investigation without determining whether abuse had occurred.
When state inspectors interviewed the current director of nursing on November 20, she defended the facility's handling of the incident. She stated it was not Resident #1's "normal behavior" and that she didn't consider it abuse because "no one saw the incident happen and neither resident could tell them what happened, and that neither resident received injuries."
The director of nursing defined resident-to-resident abuse narrowly, saying it would require one resident "seeking out another resident, like intentionally following them around, trying to push the other resident." Since Resident #1 hadn't exhibited those specific behaviors, she argued, the incident didn't qualify as abuse.
But the facility's vice president of human resources, who was serving as interim administrator during the inspection, contradicted that interpretation. She told inspectors that "resident to resident abuse would be any unprovoked physical contact between residents" and that the October 10 incident "would warrant an investigation by the AC [abuse coordinator]."
She acknowledged that while the director of nursing had looked into the incident, she could only locate one formal investigation document - a brief summary typed on a blank piece of paper. The vice president confirmed that the abuse coordinator was responsible for investigating abuse allegations and that the previous administrator had served in that role on October 10.
The incident wasn't isolated. Inspection records revealed that Resident #1 had been "care planned for the potential to be physically aggressive" after he pushed another resident on January 25. His care plan included interventions like monitoring for agitation, redirection, giving him choices, and intervening before agitation escalates.
Despite these documented aggressive behaviors and the specific care plan addressing them, the facility failed to conduct the thorough investigation required by its own policies when the October incident occurred.
The facility's abuse, neglect and exploitation policy, last reviewed in May, clearly states that "an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur." The policy designates the administrator as responsible for "determining what actions (if any) are needed for the protection of residents" upon receiving any allegations of abuse.
State inspectors attempted to interview the previous administrator who had served as abuse coordinator during the October incident, leaving a voicemail on November 20 at 10:55 a.m. The administrator never returned the call.
When inspectors observed both residents during their November visit, they found them "well groomed and dressed appropriately" but confirmed both were "pleasantly confused and unable to participate in interviews due to severe cognitive impairments."
The inspection revealed a fundamental disagreement within the facility's leadership about what constitutes resident-to-resident abuse and when investigations are required. While the director of nursing applied a restrictive interpretation that essentially required proof of intent and pattern, the interim administrator acknowledged that any unprovoked physical contact between residents should trigger an investigation.
This inconsistency left vulnerable residents without proper protection. The facility's own incident reports documented that one resident with known aggressive tendencies had physically contacted another resident, leaving the victim on the floor and unable to free himself. Staff found the aggressor holding the victim down by the shoulders while the victim struggled to get up.
Yet because no staff member witnessed the initial moment of contact, administrators decided no formal abuse investigation was necessary. The psychiatric evaluation of Resident #1 and new care orders suggested clinical staff recognized the seriousness of the incident, but the administrative response fell short of the facility's own policy requirements.
The inspection found the facility in violation of federal requirements for investigating and reporting incidents of potential abuse. State inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
The case illustrates how nursing homes can fail vulnerable residents not just through direct neglect, but by inadequately investigating incidents that leave residents at continued risk. Both residents involved in the October incident remain at the facility, their safety dependent on staff vigilance and proper implementation of care plans designed to prevent future aggressive episodes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodway Rehabilitation and Healthcare Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
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