The wheelchair's left brake couldn't grip its bald tire.
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The resident, identified in inspection records only as Resident 1, had been admitted to the facility on a date redacted from public records.
The resident at Life Care Center of Kennewick had been admitted with a brain injury that caused loss of consciousness, stroke damage, and a history of falling.
Inspectors documented that interventions to increase staff awareness of the resident's elopement risk had not been added to the care plan.
The CNA stepped between the residents and separated them.
The violent incident unfolded during a two-day stay at Boulder Park Terrace in July.
The director of nursing confirmed this directly to inspectors.
The Assistant Director of Nursing acknowledged the facility's policy requires leaving a discharge note and confirmed this was not done.
The inspection, completed August 15, 2025, was triggered by a complaint.
The August incident exposed critical failures in the facility's wandering prevention systems.
His left side did not work the way it once had.
The patient, identified in inspection records only as Resident 3, is cognitively intact.