The same staff member, identified as Staff F, also threatened to drop the resident during transfers and suggested she should be placed on hospice care to help with her anxiety. The resident would plead "please don't drop me" during these interactions.
Staff F seemed annoyed by the resident during care routines, according to witness accounts from other employees. When using the mechanical lift to transfer the resident into her wheelchair, the bars of the lift often came close to hitting her head. Another staff member, Staff A, reported that Staff F would pull back abruptly on the sling while lowering the resident and make the comment about hoping she would hit her head.
The resident, identified as Resident #2 in inspection documents, has intellectual disabilities and was afraid of falling when staff rolled her in bed. She was particularly frightened when her head would be positioned down and looking at the floor.
A certified nursing assistant, Staff H, provided a written statement dated May 1, 2025, describing Staff F as "more mean to Resident #2 compared to other residents" and "more verbally aggressive." Staff H could not remember the specific date when these incidents occurred.
When confronted by inspectors on October 21, 2025, Staff F denied ever telling a resident to shut up. She claimed she only suggested hospice care because "it would be a good thing to help her with her anxiety." Staff F said she had known Resident #2 for over 19 years and had worked with her previously when the resident lived in a group home for intellectual disabilities.
"I was familiar with how to interact with her," Staff F told inspectors.
Staff F acknowledged that Resident #2 was afraid of falling during transfers, especially when being repositioned in bed. She claimed she tried to reassure the resident by saying "we're not going to let you fall."
However, Staff F's explanation contradicted witness accounts of her behavior. After the initial allegations surfaced in May, Staff F said she thought it would be best not to care for Resident #2 "so there wouldn't be any more false allegations."
The facility issued Staff F a written warning on May 6, 2025, following the abuse allegations. An Employee Corrective Action Form documented that expectations included speaking to residents "with dignity, respect and to provide great customer services."
Staff F was required to complete re-education on the facility's abuse policy and additional training on abuse prevention before returning to work. During the disciplinary meeting, Staff F was confronted about her treatment of Resident #2.
Her response was dismissive: "I had known the resident for a long time and I just know how she is."
Management counseled Staff F to consider her tone and how it might be perceived by other staff and visitors. Both Staff F and management agreed she would not work with Resident #2 for the time being.
The Executive Director and Director of Nursing told inspectors they were first informed of concerns about Staff F on May 1, 2025, but did not have specific dates when the incidents occurred. The Executive Director said a family member for Resident #2 had reported that when the resident lived in the group home, staff there "had to treat her as if she was a 4-year-old."
The Executive Director responded that such treatment "was not acceptable in the nursing home environment."
Federal regulations require nursing homes to ensure residents are free from verbal, sexual, physical or mental abuse. The facility's own policy, titled "Freedom From Abuse Notice to Employees Resident/Patient Abuse, Neglect and Mistreatment of Belongings," specifically states that each resident has the right to a dignified existence.
The policy defines abuse as including "verbal abuse, oral, written, gestures language, including sarcastic remarks and derogatory statements, directed to residents' family members or significant others."
Staff F's comments about hoping the resident would hit her head and her threats to drop the resident during transfers constitute exactly the type of verbal abuse and sarcastic remarks prohibited by both federal regulations and facility policy.
The case highlights particular vulnerabilities faced by residents with intellectual disabilities in nursing home settings. Resident #2's fear of falling and her pleas not to be dropped during transfers demonstrate her awareness of the threatening behavior, despite her cognitive limitations.
The fact that Staff F had worked with this resident for nearly two decades, including during her time in a group home, makes the abusive behavior more troubling. Rather than using her familiarity to provide better care, Staff F appeared to use her knowledge of the resident's fears and vulnerabilities to intimidate her.
Other staff members witnessed the abuse but the facility was not notified until months after the incidents occurred. The delay in reporting allowed the abusive behavior to continue unchecked.
Even after receiving the written warning and completing mandatory retraining, Staff F continued to characterize the allegations as false rather than acknowledging any wrongdoing. Her statement that she avoided caring for the resident to prevent "more false allegations" suggests she viewed herself as the victim rather than accepting responsibility for her actions.
The inspection found the facility in violation of federal requirements to protect residents from abuse. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
However, for Resident #2, who spent her days fearing transfers and pleading not to be dropped, the impact was far from minimal. She remains at the facility, still requiring the daily care that had become a source of fear and humiliation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Aurelia, LLC from 2025-10-21 including all violations, facility responses, and corrective action plans.
Additional Resources
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