The October assault left the resident with a nasal fracture after the aide "was driving his elbow into Resident #1's face," according to a witness interviewed by inspectors. The witness, Resident #2, told investigators he thought the aide "was trying to kill Resident #1."
Federal inspectors classified the incident as immediate jeopardy to resident health and safety, the most serious violation level possible.
The altercation began when the resident and CNA A "got into it" and "were going at it bad," according to Resident #2's account to inspectors on October 27. The witness said he "heard a commotion, ran around the corner and saw Resident #1 hit CNA A."
What happened next escalated far beyond any reasonable response.
"CNA A then threw Resident #1 on the floor and Resident #1 grabbed CNA A's hair," Resident #2 told inspectors. "He/She saw CNA A take his/her elbow and ram it into Resident #1's face."
The witness described a sustained attack. "They were fist fighting at first, then CNA A was driving his/her elbow into Resident #1's face," he told inspectors. "CNA A charged Resident #1, hit Resident #1 and threw Resident #1 on the floor."
The violence continued until other staff intervened. "The other staff finally pulled CNA A off Resident #1," according to the witness account.
Resident #2, whose mental capacity was documented as cognitively intact in facility records, provided specific details about the aide's actions. He told inspectors the aide "was using his/her elbow ramming into Resident #1's face" and that "it scared him/her when he/she saw how aggressive CNA A was."
The aide offered a different version of events during his interview with inspectors on October 27. He claimed he and the resident "kind of 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 said he "was on top of the resident with his/her shoulder was about head high to the resident when they landed on the floor."
CNA A told inspectors he was "pushing on the resident because the resident had his/her hair" and "denied striking the resident in any way." He said he "did not know how anyone saw him/her hit the resident with a closed fist, because the resident was in front of him/her."
The aide's explanation contradicted the witness account in fundamental ways. While CNA A claimed the resident was face down, Resident #2 told inspectors that "the resident was laying on his/her back with his/her face up" and that "CNA A's upper body was on top of the resident's body and they were facing each other."
LPN A, who observed the incident, corroborated the witness description. The licensed practical nurse told inspectors on October 27 that "when he/she observed CNA A and the resident on the floor, 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."
CNA A told inspectors that "if he/she would have hit the resident in the face, the resident's face would show it." But medical evidence contradicted this claim.
The facility's Medical Director confirmed the resident sustained a nasal fracture during the altercation. During his interview on October 27, the Medical Director said he "did recall the assault that occurred a couple of days ago with the resident" and that "due to the staff repeatedly hitting the resident, the incident was abuse."
The Medical Director was explicit about the inappropriate nature of the aide's actions. "It was inappropriate for CNA A to continue to hit the resident," he told inspectors. He "confirmed the nasal fracture, but was hesitant to confirm a closed head injury due to the lack of testing."
The facility's Director of Nursing also classified the incident as abuse during her interview with inspectors on October 30. She told them "the altercation with CNA A and the resident was abuse."
The aide mentioned to inspectors that "there is no camera on the hall, it had been ripped out before he/she started," suggesting the absence of video evidence of the assault.
During his interview, CNA A told another nursing aide to "write a statement and to be truthful," though the inspection report does not detail what that aide witnessed or reported.
The physical evidence supported the witness accounts rather than the aide's version. The aide claimed the resident's face "could've hit the rail on the way down" as they "were on the floor next to the wall," but this explanation failed to account for the sustained nature of the assault described by witnesses.
Federal inspectors determined the facility had "implemented corrective action to remove the immediate jeopardy violation" by the time of their abbreviated survey. The severity level was reduced from immediate jeopardy to a lower classification by the time inspectors completed their exit.
However, inspectors noted that this reduction "does not denote that the facility has complied with State law requiring that prompt remedial action be taken to address Class I violation(s)."
The incident represents a fundamental breakdown in resident protection at Bridgewood Health Care Center. A cognitively intact witness described watching an aide repeatedly elbow a resident in the face while the resident lay on his back on the floor, breaking the resident's nose in the process.
The facility's own Medical Director and Director of Nursing both classified the aide's actions as abuse, contradicting the aide's claims that he was merely trying to free himself from the resident's grasp on his hair.
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.