The violent altercation left the resident with a nasal fracture. A witness told inspectors they thought the aide was "trying to kill" the resident.
Federal inspectors conducted the complaint investigation on November 25, documenting what the facility's own medical director called "abuse" by staff who "repeatedly hit the resident."
The incident began when Resident #1 and certified nursing assistant CNA A "got into it," according to Resident #2, who witnessed the altercation. The cognitively intact resident told inspectors on October 27 that "CNA A hit Resident #1 and beat him/her up really bad."
"He/She heard a commotion, ran around the corner and saw Resident #1 hit CNA A," according to the inspection report. "CNA A then threw Resident #1 on the floor and Resident #1 grabbed CNA A's hair."
What happened next horrified the witness.
"He/She saw CNA A take his/her elbow and ram it into Resident #1's face," the resident told inspectors. "He/She thought CNA A was trying to break Resident #1's neck at first."
The witness described escalating violence: "They were fist fighting at first, then CNA A was driving his/her elbow into Resident #1's face."
CNA A's version of events differed sharply from the witness account. During his October 27 interview with inspectors, the aide claimed he and the resident "spun around as they fell" and that "the resident was face down on the floor with the right side of his/her face towards the floor."
He insisted he was "on top of the resident with his/her shoulder was about head high to the resident when they landed on the floor" and was "pushing on the resident because the resident had his/her hair."
The aide denied striking the resident. "He/She denied striking the resident in any way and did not know how anyone saw him/her hit the resident with a closed fist, because the resident was in front of him/her," according to the inspection report.
But CNA A's account contradicted what other staff witnessed. LPN A told inspectors that when they observed the altercation, "the resident was laying on his/her back with his/her face up" and "CNA A's upper body was on top of the resident's body and they were facing each other."
This positioning aligned with the witness resident's description of CNA A repeatedly elbowing the victim in the face.
The aide told inspectors that "if he/she would have hit the resident in the face, the resident's face would show it." Medical evidence proved otherwise.
During an October 27 interview, the facility's medical director confirmed the resident suffered a nasal fracture from the incident. The doctor told inspectors that "due to the staff repeatedly hitting the resident, the incident was abuse" and "it was inappropriate for CNA A to continue to hit the resident."
The medical director was "hesitant to confirm a closed head injury due to the lack of testing," but acknowledged the severity of what occurred.
The witness resident provided chilling details about the aide's aggression. "CNA A charged Resident #1, hit Resident #1 and threw Resident #1 on the floor," they told inspectors. "It scared him/her when he/she saw how aggressive CNA A was and was using his/her elbow ramming into Resident #1's face."
The violence continued until other staff intervened. "The other staff finally pulled CNA A off Resident #1," the witness said, describing how "the nurse and the aides pulled them apart, because the resident still had his/her hair."
Even then, the struggle wasn't over. According to CNA A's own account, "they had his/her arms and the resident had his/her hair" when staff separated them.
The aide noted there was "no camera on the hall, it had been ripped out before he/she started," leaving no video evidence of the assault.
Three days after the incident, the facility's Director of Nursing confirmed to inspectors that "the altercation with CNA A and the resident was abuse."
The inspection report notes that CNA A "encouraged CNA B to write a statement and to be truthful," though the aide maintained his innocence despite the medical evidence and witness testimony.
Federal inspectors initially classified the violation at the immediate jeopardy level, meaning the facility's failures posed immediate threat to resident health and safety. By the time inspectors completed their abbreviated survey, the facility had implemented corrective actions to address the immediate jeopardy.
The severity level was reduced, though inspectors noted this "does not denote that the facility has complied with State law requiring that prompt remedial action be taken to address Class I violation(s)."
A final revisit will determine whether Bridgewood Health Care Center achieves substantial compliance with federal participation requirements.
The incident highlights the vulnerability of nursing home residents to staff violence. The witness resident's fear was palpable in their statement to inspectors: they thought the aide was going to kill the victim during the brutal assault.
For Resident #1, the physical injuries from the nasal fracture represent just the beginning of recovery from an attack that should never have happened in a place meant to provide care and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bridgewood Health Care Center from 2025-11-25 including all violations, facility responses, and corrective action plans.