The failure at Brookside Care Center left both residents without protective interventions and placed them at risk for psychological harm, according to a November inspection report. State regulations require nursing homes to report alleged abuse incidents within 24 hours of discovery.
The victim told inspectors on November 20 that Resident 2 had urinated on the floor and thrown the utensils at her during the October incident. The objects missed her. She reported what happened to both the activities director and the Director of Nursing.
Nobody called the state.
Resident 1 lives with generalized anxiety disorder and depression. Resident 2 has dementia, anxiety, and metabolic encephalopathy, a brain dysfunction that causes confusion, memory problems, and changes in behavior.
The Assistant Director of Nursing acknowledged during the inspection that the Department wasn't notified about the knife and fork incident. As a mandatory reporter for alleged abuse cases, she said, the event needed to be reported within two hours.
"It put Resident 1 and Resident 2 at risk for harm especially when the interdisciplinary team was not aware of the incident," the Assistant Director told inspectors.
The interdisciplinary team includes health care professionals with various areas of expertise who work together toward residents' goals. Without knowing about the incident, they couldn't develop safety measures or interventions.
The Director of Nursing also acknowledged the event was alleged abuse that should have been reported within two hours. She told inspectors there was potential risk for harm for both residents.
During a joint interview on November 21, the Administrator and Director of Nursing reviewed the facility's policy on reporting allegations of abuse, neglect, and exploitation. The undated policy states that all allegations must be reported to the facility Administrator and to other appropriate agencies.
The procedure requires staff to notify appropriate agencies immediately, "as soon as possible, but no later than 24 hours after discovery of the incident."
Both the Administrator and Director of Nursing agreed the facility's reporting process wasn't followed for the alleged resident-to-resident abuse incident. They acknowledged the Department wasn't notified about what happened.
The Director of Nursing said the interdisciplinary team couldn't follow up because they weren't aware of the allegation until the state surveyor informed them during the inspection.
The inspection occurred more than a month after the October incident. The resident who was targeted had already told two different supervisors what happened, but the facility's own interdisciplinary team remained unaware.
Resident-to-resident incidents require immediate assessment and intervention, particularly when one resident has dementia and behavioral changes. Metabolic encephalopathy can cause unpredictable behavior, confusion, and memory problems that affect a person's ability to control their actions.
The victim's existing anxiety disorder and depression made her particularly vulnerable to psychological harm from the incident. Generalized anxiety disorder causes constant fear, feelings of being overwhelmed, and excessive worry about everyday situations.
Without proper reporting and team intervention, both residents remained at risk. The resident with dementia continued without behavioral assessments or environmental modifications that might prevent future incidents. The victim continued without additional support or safety measures.
State inspectors classified the violation as causing minimal harm or potential for actual harm. The facility failed to respond appropriately to alleged violations by not reporting the incident within required timeframes.
The inspection was conducted in response to a complaint. Inspectors found that few residents were affected by the reporting failure, but the consequences extended beyond the two individuals involved.
When nursing homes fail to report alleged abuse, the state cannot investigate, provide oversight, or ensure appropriate interventions are implemented. The facility's interdisciplinary team cannot develop protection plans or modify care approaches without knowledge of incidents.
The facility's own policy required reporting within 24 hours, but staff followed neither the facility's internal requirement nor the state's two-hour mandate for suspected abuse cases.
The Assistant Director of Nursing, Director of Nursing, and Administrator all acknowledged during interviews that proper procedures weren't followed. Each confirmed the incident should have been reported and that both residents remained at risk without team awareness and intervention.
The resident who reported the incident had trusted facility staff with information about being targeted with potentially dangerous objects. She told both the activities director and Director of Nursing what happened. Despite her reports to two supervisors, the facility's response system failed.
The knife and fork didn't strike the intended target, but the incident represented escalating behavior from a resident with dementia and brain dysfunction. Without proper assessment and intervention, similar or more serious incidents remained possible.
Both residents continued living in the facility without the protective measures that should have followed the October incident. The interdisciplinary team never developed safety protocols, behavioral interventions, or environmental modifications that might have prevented future problems.
The inspection found that Brookside Care Center's failure to follow state reporting requirements left vulnerable residents without required protections and placed them at ongoing risk for psychological harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookside Care Center from 2025-11-21 including all violations, facility responses, and corrective action plans.