The resident, identified as Resident C in the inspection report, told investigators on October 20 that Certified Nursing Assistant 2 "said a lot of hurtful things" to her. The comments included telling her that nobody at the facility liked her and that she was a difficult resident to take care of and roll over.
Two other nursing assistants witnessed the verbal abuse and confirmed the resident's account to inspectors.
CNA 3 told investigators she was in the room when CNA 2 made the comments, confirming that the assistant told the resident she was difficult to care for. CNA 4 provided additional details about a separate incident where she and another staff member were providing care to Resident C when CNA 2 entered the room.
"The resident made a remark that she was easy to care for, and CNA 2 told her she was one of the most difficult people at the facility to care for," CNA 4 told inspectors.
After CNA 3 and CNA 4 left the room, CNA 2 remained behind with the resident. When the resident later turned on her call light for assistance with hygiene, CNA 2 was no longer in the room, and the resident no longer wanted to get out of bed.
The verbal abuse went beyond individual comments. According to the inspection report, CNA 2 also told the resident there were "three types of people in this facility: those that take care of themselves, those that need a little help, and like Resident C that can't do anything on their own."
Resident C, whose medical record shows she was admitted in August with diagnoses including heart failure, depression, and hypertension, reported the treatment to management. A registered nurse interviewed her on October 8 about the incidents.
During that interview, documented in facility records, the resident expressed that she was upset CNA 2 had told her she was hard to roll and that other staff members talked about her. While CNA 2 later apologized, the resident told the nurse she still felt ridiculed and embarrassed.
The facility responded by ensuring CNA 2 no longer provides care to Resident C. However, the damage to the resident's sense of dignity had already occurred.
An admission assessment from August 22 confirmed that Resident C was cognitively intact, meaning she fully understood the hurtful nature of the comments directed at her. The psychological impact of being told that staff disliked her and found her burdensome would be particularly acute for someone with depression, one of her documented diagnoses.
The inspection findings violated federal regulations requiring nursing homes to ensure residents are treated with dignity and respect. The facility's own policy, titled "Your Rights and Protections as a Nursing Home Resident," explicitly states that residents "have the right to be treated with dignity and respect."
The presence of multiple witnesses to the verbal abuse suggests the behavior occurred openly, raising questions about the facility's culture and supervision of staff interactions with vulnerable residents. That two different nursing assistants independently corroborated the resident's account demonstrates the incidents were not isolated misunderstandings but clear violations of basic human decency.
The timing of the incidents also raises concerns. The verbal abuse occurred after the resident had been at the facility for several weeks, suggesting staff had time to develop negative attitudes toward her care needs rather than approaching her with professional compassion.
Federal inspectors classified the violation as causing minimal harm with the potential for actual harm, affecting few residents. However, for Resident C, the psychological damage was immediate and lasting, leaving her feeling unwanted and dehumanized in what should have been a safe environment during her recovery.
The case illustrates how quickly staff attitudes can destroy a resident's sense of dignity and belonging. Despite the facility's written policies promising respectful treatment, the reality for Resident C was a nursing assistant who made her feel like a burden and told her that her caregivers disliked her.
The investigation stemmed from a complaint, suggesting either the resident or someone acting on her behalf felt compelled to report the treatment to authorities. That step required courage from someone already vulnerable and dependent on the facility for daily care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Clifty Falls, The from 2025-10-20 including all violations, facility responses, and corrective action plans.