Bywood East Health Care: Abuse Ignored After Hair-Pulling - MN

That was December 8. Eleven days later, when a federal inspector arrived at Bywood East Health Care on Central Avenue Northeast, the resident who had been grabbed by the hair was still in the hospital. The resident who had grabbed her was still on the same floor. And the facility had never opened an abuse investigation.

The inspection, completed December 19, 2025, found that Bywood East had failed to protect a resident — identified in records only as Resident 1 — from repeated, documented aggression by another resident, Resident 2, a woman with cognitive impairment who had been seeking out Resident 1 and physically touching her on multiple occasions. Inspectors cited the facility for causing actual harm to a resident.

The director of nursing, who told inspectors she had worked at the facility for approximately four months, confirmed she was notified on December 8 that Resident 2 had pulled Resident 1's hair. She did not report it as a potential abuse allegation. She did not investigate it. Her explanation, offered during a group interview the morning of the inspection, was that Resident 1 becomes easily upset with many things.

Resident 1 was taken to the hospital that same day. She was still there when inspectors arrived nearly two weeks later.

What the inspection record describes is not a single incident but a pattern. Direct care staff had watched Resident 2 seek out Resident 1 repeatedly. They had seen the interactions escalate. They had formed their own view of what was happening — that Resident 2 was specifically and persistently targeting Resident 1 — and they had not passed that information up the chain. The director of nursing and the social worker both acknowledged during the interview that none of the floor staff had reported this pattern to them. The director of nursing said that if they had known, they would have brought in the facility's Abuse Care Process team and used the Behavioral Assessment Form to develop a plan.

Nobody had.

The social worker, who told inspectors she was in her third week at the facility, reviewed Resident 1's care plan during the interview and confirmed there were no specific goals or interventions addressing Resident 2 at all — despite Resident 2 being what the social worker herself called a known agitator of Resident 1. The director of nursing attributed this to the previous social worker's poor job performance.

The facility's primary response to Resident 2's behavior had been redirection. Staff redirected her daily, the administrator said. There were no one-on-one checks. No fifteen-minute safety monitoring. No floor separation had been attempted or even discussed at an interdisciplinary team meeting, the director of nursing acknowledged, adding that a floor change probably wasn't feasible anyway because both residents needed help with activities of daily living.

The administrator joined the interview at 11:26 a.m. Her position was that Resident 2 was not willfully seeking anyone out. Resident 1, she said, was paranoid and anxious, and those traits caused her to believe she was being targeted. The administrator said the facility was working on discharging Resident 2 to a more appropriate care setting and expected that to happen within the next week or so.

She also said: "I think we're not taking credit for a lot of the redirection we are doing."

The facility's own abuse prevention policy, number 2218, defines mental abuse as verbal or nonverbal contact that causes fear, shame, agitation, or degradation. The same policy states the facility will identify patterns and trends that may constitute abuse and investigate them. It requires all allegations of potential abuse to be immediately reported to the administrator and then investigated.

The director of nursing verified there had been no such report and no such investigation following the December 8 hair-pulling incident.

The social worker, asked about how the facility would handle similar situations going forward, said the team was still working on a process to determine whether Resident 1's reported fears were general in nature or specific to a single person or event. That determination, she explained, would help them figure out in the future what was reportable.

The licensed practical nurse and MDS coordinator who participated in the interview offered a different framing of Resident 1's experience. She felt it was more anxiety than actual fear, she said. The administrator echoed that view.

What the inspection report does not reflect is any documented effort, before December 19, to ask Resident 1 what she was experiencing.

The facility had been in contact with Resident 1's guardian in the week before the inspection, the social worker said, trying to help decide how to make Resident 1 feel safer at the center. Resident 1 was not at the center. She was in the hospital, where she had been since the day she was grabbed by the hair.

The inspection found the deficiency caused actual harm and affected a few residents. Bywood East has not contested the findings in publicly available records. The facility serves residents at 3427 Central Avenue Northeast in Minneapolis.

Resident 1 remained hospitalized as of the date inspectors completed their review. Whether she returned to Bywood East, and whether Resident 2 was still there when she did, is not reflected in the inspection record.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Bywood East Health Care from 2025-12-19 including all violations, facility responses, and corrective action plans.

Additional Resources

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