The November 3rd incident was accidentally captured on voicemail when Resident #1 mistakenly called a family member during the interaction with the aide, identified as CNA A in inspection records.
Resident #1 told inspectors he had asked the aide to remove his lunch tray so he could use his bedside table. The aide refused. After she emptied his colostomy bag, he asked again for the tray to be moved to the counter or sink area, not removed from the room entirely.
She still refused.
"I just could not understand why she would not take the tray," Resident #1 told inspectors during their November 20th visit. He said the incident caused him no harm or mental anguish, but he remained puzzled by the aide's refusal to help with such a simple request.
The voicemail recording, reviewed by inspectors, confirmed the aide's refusal to remove the tray as requested.
LVN B was in the room during part of the interaction, disconnecting Resident #1's IV treatment that had finished. She told inspectors she heard the resident and aide talking back and forth but was focused on her task. No voices were raised, she said, and she heard nothing derogatory that would have prompted her to intervene.
"I did not recall Resident #1 asking for his lunch tray to be removed, because I would have removed it myself," LVN B told inspectors. She said she was concentrated on finishing her work so she could return to her assigned hall.
The administrator listened to the voicemail recording and determined the aide's behavior wasn't demeaning or intentional, telling inspectors the facility "would have partied ways with the staff member" if it had been. Instead, he characterized it as a customer service issue.
"His expectations of his staff was to provide good customer service and do whatever we can for the residents if it is safe," according to the inspection report.
CNA A was suspended for approximately one week. When she returned to work, facility policy prevented her from caring for Resident #1. She also received additional training on customer service and resident rights on November 11th, conducted by the administrator, director of nursing, and staffing coordinator.
The facility's resident rights policy, dated February 2021, guarantees residents "a dignified existence" and the right to "be treated with respect, kindness and dignity." The policy also ensures residents can "exercise his or her rights without interference, coercion, discrimination or reprisal from the facility."
Federal inspectors cited Carrara for failing to ensure residents could exercise their rights without interference, finding the aide's refusal violated the resident's right to dignified treatment.
The inspection, conducted as a complaint investigation, found minimal harm with few residents affected. The facility's corrective actions included the suspension, retraining, and policy enforcement regarding the specific aide's assignment restrictions.
Resident #1 remains at the facility. The aide who refused his simple request has returned to work but cannot provide his care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carrara from 2025-11-20 including all violations, facility responses, and corrective action plans.