Resident D told inspectors during an October 22 interview that CNA 3 was rough during incontinence care and "it made her sore." She had asked the aide to go easy. He would say okay, but didn't change his approach.
The resident said CNA 3 was rushing with care and she felt it was disrespectful to her. Despite the problems, she told inspectors that other than the rushing, "he was a good guy."
Resident D had reported the rough treatment to a nurse and some of the other nursing assistants, though she didn't know their names. Staff never filled out a grievance form for her about the matter.
The resident was cognitively intact for daily decision making and was described as reasonable and consistent, according to her October 1 admission assessment. She had no behavioral issues documented.
Her medical conditions included congestive heart failure, respiratory failure, chronic obstructive pulmonary disease, atrial fibrillation, diabetes, depression, anxiety, and morbid obesity. She was frequently incontinent of urine and always incontinent of bowels.
The facility's resident rights policy, provided by the executive director during the inspection, stated that residents have the right to be treated with dignity and respect. Each resident "shall be treated with consideration, respect and full recognition of dignity and individuality, including care of personal needs."
The policy also specified that residents have "the right to a dignified existence."
Inspectors reviewed Resident D's case as part of examining dignity violations at the 990 North 16th Street facility. They found the facility failed to provide dignified incontinence care, citing minimal harm with the potential for actual harm.
The inspection was conducted in response to a complaint. Federal surveyors completed their review on October 23.
Resident D's case illustrates how routine care can become undignified when staff rush through intimate procedures. The resident's multiple medical conditions, including her incontinence issues, required careful attention during personal care.
Her complaints to multiple staff members about CNA 3's rough treatment went unaddressed through the facility's formal grievance process. The resident had specifically told the aide to be gentler, but he continued the same approach despite acknowledging her request.
The facility's own policy emphasized treating residents with "full recognition of dignity and individuality" during personal care. Resident D's experience with CNA 3 fell short of this standard.
Incontinence care represents one of the most vulnerable moments for nursing home residents. The resident trusted staff enough to report the problem to nurses and other aides, but the facility's response system failed to protect her from continued rough treatment.
The resident's assessment showed she was mentally capable of making decisions about her care and communicating her needs. Her complaint about soreness during care was a clear indication that something was wrong with CNA 3's technique.
Federal regulations require nursing homes to ensure residents can exercise their rights, including the right to dignified treatment during all aspects of care. Resident D's repeated complaints about rough incontinence care represented a violation of this fundamental protection.
The inspection found that despite the resident's clear communication about the problem and her reports to multiple staff members, the facility failed to take formal action through its grievance process. This left her vulnerable to continued undignified treatment during one of the most personal aspects of nursing home care.
Resident D's experience shows how a facility can fail to protect residents' dignity even when they speak up about problems. Her complaints about CNA 3's rushing and rough treatment during incontinence care went unresolved, leaving her to endure continued discomfort and disrespect during intimate personal care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonebrooke Rehabilitation Center from 2025-10-23 including all violations, facility responses, and corrective action plans.
Additional Resources
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