The incident occurred at Fortuna Rehabilitation and Wellness Center, where the resident had been receiving palliative care since October 2025. The patient, identified in inspection records as Resident 1, has acute chronic heart failure, hearing loss, muscle weakness, and an amputated left leg below the knee.
The nursing assistant, identified as CNA 1, was overheard yelling and swearing at the resident during the shower. When interviewed by inspectors on January 29, the resident confirmed that CNA 1 "yelled and sweared at him and he did not like how he was treated."
Federal inspectors found the resident was "visibly bothered" when interviewed about the incident.
The facility's administrator requested the nursing assistant's termination in an email to corporate headquarters on January 12. "I am requesting to terminate employee [CNA 1] for abuse," the administrator wrote at 12:30 p.m. "The employee was overheard while providing a shower to a resident yelling and swearing. The resident was visibly bothered upon the interview."
The Director of Nursing told inspectors on January 29 that the facility had substantiated the abuse allegation and terminated CNA 1.
Records show the resident had been admitted for specialized palliative care, which focuses on providing relief from symptoms, pain and stress for people with serious or life-threatening illnesses. A federal assessment from January 10 indicated he had slight memory impairment in addition to his physical conditions.
The facility updated the resident's care plan on January 12 to reflect that he was "a victim of alleged abuse secondary to CNA [1] yelling at him when in the shower and calling him an asshole."
Fortuna Rehabilitation's abuse prevention policy, effective in 2024, explicitly prohibits verbal abuse. The policy defines verbal abuse as "any use of oral, written, gestured communication, or sounds that willfully includes despairing and derogatory terms directed to resident."
The policy states: "The facility does not condone any form of resident abuse."
Federal regulations require nursing homes to protect residents from all forms of abuse, including verbal mistreatment. Inspectors found the facility failed to protect this resident from abuse when the incident occurred.
The inspection was conducted following a complaint. Inspectors reviewed records and interviewed staff and the affected resident as part of their investigation into the allegation.
The resident's vulnerability made the abuse particularly concerning to inspectors. Beyond his physical limitations from the amputation, heart condition, and hearing loss, the patient was receiving end-of-life care designed to maximize comfort and dignity.
The timing of the administrator's termination request suggests the facility moved quickly once the abuse was reported. The email requesting CNA 1's firing was sent the same day the facility updated the resident's care plan to document the abuse incident.
When inspectors interviewed the resident more than two weeks after the incident, he remained bothered by how the nursing assistant had treated him. The resident's ability to clearly articulate what happened demonstrated the lasting impact of the verbal abuse.
The inspection found the facility's failure to prevent this abuse had "the potential to negatively impact the resident's psychosocial well-being." For a patient already dealing with serious medical conditions and receiving palliative care, the additional stress of verbal mistreatment during personal care represented a significant failure in protection.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the finding still represents a serious breach of federal requirements that nursing homes maintain environments free from abuse.
The facility was required to develop a plan of correction addressing how it would prevent similar incidents in the future. The inspection report notes that for nursing homes, findings and correction plans become publicly available 14 days after being provided to the facility.
Resident 1 continues to receive care at Fortuna Rehabilitation and Wellness Center. The facility has not reported any similar incidents since CNA 1's termination.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fortuna Rehabilitation and Wellness Center, Lp from 2026-01-29 including all violations, facility responses, and corrective action plans.