The resident told federal inspectors the aide's behavior made them feel "like they didn't matter, like staff did not care, and it made them feel bad."
Multiple staff members at Woodland Manor reported the November incident involving CNA A, who colleagues said had a pattern of providing inadequate incontinence care and speaking sharply to residents.
The resident explained during interviews that while CNA A technically allowed them to decide about wearing a brief, "really CNA A would just keep at them until the resident relented and because the resident just wanted to get along with everyone, they did not argue."
CNA C told inspectors the resident had confided that CNA A was disrespectful when denying the brief request. The resident was upset but "did not want to tell anyone because they were afraid of retaliation from CNA A."
The resident said they "hated incontinence" and that night shift aides "either did not change them often or sometimes they did not come in at all." No other staff had issues providing proper incontinence care — "only CNA A."
CNA D corroborated the account, saying there were "issues with night shift staff, specifically CNA A, not wanting or allowing the resident to sleep with an incontinent brief." The aide told the resident "it was better to sleep without anything covering their bottom, but the resident wanted to sleep in a brief."
Licensed Practical Nurse F said they had "heard CNA A's tone get a little sharp with residents before." In one case, a newer resident refused to allow CNA A in their room but wouldn't explain what happened. The resident later allowed the aide back in.
LPN F said it would be inappropriate "for staff to continue to try to change a resident's mind once they made a decision about something."
During the investigation, LPN E acknowledged hearing "stories from other CNAs" about CNA A "not providing incontinent care as often as they should" but dismissed it as "typical shift to shift rivalry."
When confronted, CNA A admitted they "may have said that their back hurt" but denied telling the resident they caused the back pain. The aide claimed "sometimes the resident did not want to wear incontinent briefs to bed, and sometimes they did" — contradicting multiple witness accounts.
CNA A acknowledged that staff "should not be disrespectful or treat residents in an undignified manner" and said they would report such behavior to supervisors.
The facility's administrator confirmed it was inappropriate to tell residents they caused staff injuries and that "if a resident wanted to wear a brief to bed, staff should not guilt a resident into doing something they did not want to do."
Federal inspectors cited Woodland Manor for failing to ensure residents were treated with dignity and respect. The violation carried minimal harm but affected the resident's psychological well-being and autonomy over basic personal care decisions.
The resident's fear of retaliation prevented them from initially reporting the mistreatment. They told inspectors they simply wanted to avoid conflict, even when it meant accepting care that made them feel devalued and uncomfortable throughout the night.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodland Manor from 2025-11-29 including all violations, facility responses, and corrective action plans.