The resident, identified as R6 in the October inspection report, had been admitted to Metropolis Rehab & HCC in February with acute respiratory failure, heart failure, chronic obstructive pulmonary disease, and dementia. She wrote down what the nurse said to her on a piece of paper she kept by her bedside: "choke on that, it's all in your head, you can breathe if you try, you are crazy."
R6 was visibly upset when she showed the handwritten list to state inspectors on October 16. She told them the incidents happened on multiple dates and that she was scared when the nurse, V56, refused to help her during breathing episodes.
The first report came on October 15 at 10:31 PM, when certified nursing assistant V59 found R6 crying and upset. R6 told V59 that the licensed practical nurse had called her ridiculous and yelled in her face. V59 told R6 to report it to the administrator the next day but never reported it herself because she hadn't witnessed the abuse.
Another nursing assistant, V51, said R6 reported the verbal abuse to her "quite a few times" on unknown dates. R6 told V51 she was afraid of the nurse and that V56 was "verbally mean to her." V51 said she reported the allegations to both the administrator and director of nurses.
But when inspectors interviewed the facility's leadership, neither knew about the reports.
Director of Nurses V2 told inspectors on October 20 that she was "unaware of any allegations of verbal abuse regarding V56 and R6." The administrator, V1, said the same thing the next day, adding that allegations "should have been reported immediately."
In the same interview, the director of nurses contradicted herself. She said staff had reported that R6 was upset with a staff member, but when she talked to R6 directly, "she told V2 she didn't want anyone to get in trouble."
Only after inspectors raised the issue did the administrator begin an investigation on October 22. She told inspectors she had spoken with R6's power of attorney, who confirmed R6 had complained about a nurse calling her ridiculous.
The investigation report, dated October 21, documented that a state surveyor had reported the verbal abuse allegations to the abuse coordinator and director of nursing around 1:00 PM that day. The report noted the date and time of the incidents were "uncertain" and that the investigation was "immediately initiated."
By then, it was too late for any meaningful accountability. The nurse, V56, had been discharged from employment on October 2. R6 had been discharged from the facility on October 17, the day after she showed inspectors her handwritten record of the abuse.
The facility's own abuse prevention policy, dated March 2025, requires that "resident abuse must be reported immediately to the Administrator." The policy violation affected one of three residents reviewed for abuse in the inspection sample.
R6's medical records showed she was independent in making consistent and reasonable decisions, with no cognitive impairment documented in her August assessment. Her care plan contained no focus area related to abuse or behavioral issues.
The breakdown in reporting meant that for weeks, a resident with serious respiratory conditions faced verbal abuse from the very staff member responsible for her medical care. When she gasped for air, the nurse told her to "choke on that." When she expressed fear, the nurse called her "crazy."
Multiple staff members knew about the allegations. At least two reported them to supervisors. But the facility's leadership either ignored the reports or failed to act on them until federal inspectors arrived and discovered R6's handwritten evidence.
The resident's own words, scrawled on paper and kept beside her bed, became the most damning evidence against a system that failed to protect her when she was most vulnerable.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Metropolis Rehab & Hcc from 2025-11-17 including all violations, facility responses, and corrective action plans.