The incident at The Nichols Center occurred on October 3rd when Resident #1 called for assistance with incontinence. Certified Nursing Assistant #1 told him to use his brief and that she would return to change him. When she finally came back after 90 minutes, she told the resident, "You are in rehab and should be walking."
The facility terminated CNA #1 on October 8th, two days after placing her on investigative leave.
A second nursing assistant treated the same resident with similar disrespect just two days later. On October 5th, CNA #2 entered the resident's room to help him to the bathroom but never spoke to him during the entire interaction. The resident's responsible party witnessed the assistant throw the covers over the resident, throw the bed remote onto the bed, and slam the door on her way out.
Both the resident and his responsible party described CNA #2 as "rude and nasty." The facility also terminated this assistant on October 8th.
The resident had been admitted to the facility on September 23rd with a diagnosis of difficulty walking. A mental status evaluation showed he was cognitively intact with a score of 14 out of 15.
Administrator interviews on November 24th confirmed that both nursing assistants failed to treat the resident with dignity and respect. The Director of Nursing revealed that the resident initially couldn't identify the staff members involved, so she reviewed security video footage to obtain photos of the CNAs on duty. The resident then identified both assistants from the photographs.
The responsible party, interviewed by phone on November 24th, confirmed witnessing the second incident. She described watching CNA #2 refuse to speak to the resident during care, throw the covers over him, throw the remote onto the bed, and slam the door.
Federal inspectors found the facility violated the resident's right to dignified treatment during their November 25th complaint investigation. Facility policy, updated October 24th, explicitly states that residents have the right to dignified existence, self-determination, and communication.
The violations occurred despite the resident's cognitive ability to understand and report the mistreatment. His BIMS evaluation score of 14 indicated he was mentally intact and capable of accurately describing what happened to him.
The facility's investigation began on October 6th after the responsible party reported the bathroom incident involving CNA #2. That same day, administrators placed both nursing assistants on investigative leave before terminating them two days later.
The incidents highlight how vulnerable rehabilitation patients can become when basic dignity standards collapse. The resident, admitted for walking difficulties, found himself at the mercy of staff who treated his most basic needs with contempt.
The first assistant's command to soil himself and wait 90 minutes violated fundamental care standards. The second assistant's silent, rough treatment while helping with bathroom needs showed similar disregard for the resident's humanity.
Both incidents occurred within days of each other, suggesting a pattern of disrespectful treatment toward the same vulnerable patient. The responsible party's presence during the second incident provided crucial witness testimony that supported the resident's account.
The facility's use of security footage to identify the staff members demonstrates the importance of video surveillance in protecting residents who may struggle to identify their caregivers. Without the photographs from the security system, the resident might not have been able to name the assistants responsible for his mistreatment.
The terminations came after a brief investigation period, indicating the facility found clear evidence supporting the resident's complaints about both nursing assistants' conduct.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Nichols Center from 2025-11-25 including all violations, facility responses, and corrective action plans.