Failure to Report Abuse Allegations Immediately
Summary
The facility failed to ensure that all allegations of physical and/or emotional abuse were reported immediately to the Administrator and State Survey Agency as required. This resulted in Immediate Jeopardy and the potential for serious harm beginning when an Activity Director witnessed a State tested Nursing Assistant (STNA) forcibly placing a resident into a tilt-in-space wheelchair and inverting the chair, causing distress to the resident. The incident was not reported immediately, allowing the STNA to continue providing care to residents, including the affected resident. Another incident occurred when a resident alleged physical abuse by a male STNA during a shower. The resident reported being forcefully undressed and thrown into the shower, resulting in multiple bruises and fractures. Despite the resident's report to a Licensed Practical Nurse (LPN) and her son, the allegation was not reported to leadership staff, allowing the STNA to continue working with residents. The facility's failure to report these incidents immediately to the appropriate authorities and remove the alleged perpetrators from resident care areas contributed to the deficiency. The facility's policies required immediate notification of the Director of Nursing and Executive Director of any abuse allegations, but these protocols were not followed. Staff members, including the Human Resource Manager and Unit Manager, were aware of the incidents but did not take appropriate action to report them or initiate an investigation. This lack of adherence to reporting procedures and failure to protect residents from potential harm led to the deficiency identified by the surveyors.
Removal Plan
- The Administrator/Executive Director created Self-Reported Incident regarding Resident #71's allegation of abuse.
- The Executive Director conducted interviews with Resident #71, STNA/Alleged perpetrator #200, Activities Aide #310, STNA #300, STNA #131, LPN#102 and RN# 315.
- The Administrator/ED notified the local police department of the incident with Resident #71 and STNA #200. The local police opened a case.
- ADON #100 notified Medical Director #800 of the incident with Resident #71 and STNA #200 and the incident with Resident #78 and STNA #300.
- Regional Director of Clinical Operations (RDCO) #320 created Self-Reported Incident regarding the incident between Resident #78 and STNA #300.
- The Executive Director conducted interviews with Activities Director #400, Activities Aide #310, Activities Aide #301, STNA/Alleged Perpetrator #300, STNA #131, Unit Manager #105, HRM #600, and STNA #340.
- The ED notified the local police department of the incident involving Resident #78 and STNA #300. The local police opened a case.
- 61 residents with a Brief Interview for Mental Status Score (BIMS) of 10 and higher were interviewed by ADON# 100, Clinical Manager #101, and RDCO #320 to identify any additional occurrences of abuse.
- Skin assessments were performed by LPN #430, ADON #100, Clinical Manager #101 and RDCO #320 on all other residents who had a BIMS under 10 or were not interviewable. All 102 residents were interviewed and/or assessed.
- The ED sent a text message to all 121 staff members to notify them of required in-service education being completed by RDCO #320. The education included a quiz.
- Unit Manager #105 along with the interdisciplinary team were educated by Regional Director of Operations (RDO) #750. Education included a review of proper policy and procedures on the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation.
- RDCO #320 educated Unit Manager #105 on Abuse Prevention, the use of restraints, and aggressive/combative behavior with emphasis on de-escalating catastrophic reactions, abuse investigation (including resident assessments & documentation) and reporting, and use of restraints.
- RDCO #320 educated LPN #102 on abuse reporting, including the identity of the abuse coordinator, timelines, and proper notifications in instances of abuse allegations.
- RDCO #320 educated the DON verbally via telephone on proper policies and procedures for the use of Restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation.
- The remaining 104 staff including LPN #102 and Unit Manager #105 were educated in person or via telephone on the use of restraints, Dementia Care, Aggressive/Combative Behavior, Abuse Policy, Abuse Reporting, and Abuse Investigation by RDCO#320/designee.
- The facility indicated all new hires would be educated on the first day of orientation by social service staff.
- The facility Quality Assessment and Performance Improvement (QAPI) committee met to conduct a root cause analysis of the incidents involving Resident #78 and Resident #71.
- RDCO #320/designee would audit 24-hour reports daily for four weeks to see if any reportable incidents occurred.
- The RDCO/designee would also audit to ensure facility Self-Report Incidents (SRIs) were reported to the State (ODH) agency portal in a timely fashion.
- The facility completed and submitted their final Self-Reported Incident information which substantiated the incident of abuse involving Resident #78.
- The facility completed and submitted their final Self-Reported Incident information which substantiated the incident of abuse involving Resident #71.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to report an alleged misappropriation of resident funds. A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident took it, but the SSD reportedly said it was too long ago to investigate. The CNO recalled hearing about missing funds from a family member but did not pursue it, and the CEO stated the allegation should have been reported to the State Agency.
Failure to report alleged sexual abuse within required timeframe. A resident with intact cognition and significant ADL dependence alleged that a CNA raped them during incontinence care; the resident later described possible penetration and burning, while the CNA said they only provided brief care and applied ointment. The family member contacted law enforcement and requested hospital transfer, but facility leadership did not report the allegation to DOH within 2 hours, stating they believed the allegation had changed to rough handling and did not meet the reporting threshold.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin: Staff did not immediately report two resident-to-resident sexual abuse incidents involving one resident touching two others, and staff also did not immediately report bruising of unknown origin on another resident. A CNA redirected the resident during the abuse incidents but did not notify the charge nurse, DON, or Administrator, and an RN and LPN did not escalate the bruising after assessing it and hearing it described as handprint-like. The delayed reporting prevented timely initiation of the abuse investigation process and resident assessment.
Failure to Report Alleged Physical Abuse: A resident alleged that two CNAs were rough while repositioning them in bed and that the resident’s head was bumped into the headboard, causing pain. One CNA confirmed the head bump occurred during care, and the administrator stated the abuse allegation and failure to report were substantiated because the staff did not report the incident immediately.
Failure to Timely Report Allegation of Abuse: A nurse witnessed one resident touch another resident inappropriately, but the incident was not reported within the required timeframe. The LPN separated the residents and addressed boundaries with the resident involved, but did not report the event because she believed the RN would notify the DON. The DON and Administrator later stated the incident had not been reported immediately as required.
Failure to Immediately Report Verbal Abuse Allegation: A CNA was heard using foul and disrespectful language toward a cognitively impaired resident during care, but the allegation was not reported immediately to the DON/Administrator. The witness delayed reporting for several hours, and the DON, ADON, and Administrator confirmed the report was not made until later that morning. The resident had severe cognitive impairment, was dependent on staff for care, and received nutrition via GT.
Failure to Report Alleged Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was reported to the State Agency as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months before the survey, he reported $1,600.00 missing to the Social Services Director and believed another resident had taken the money. He reported that the SSD asked how long ago it happened, and when he said about one and a half months earlier, he was told it had been too long ago to investigate. During the survey, the SSD did not respond to a call for interview, the CNO stated she recalled a family member mentioning the missing funds but did not ask further questions, and the CNO said the allegation was never made directly to her or facility staff. The CEO stated the allegation should have been reported to the State Agency.
Failure to Report Alleged Sexual Abuse Within Required Timeframe
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse was reported to the New York State Department of Health and local law enforcement within two hours of the allegation. The deficiency involved one resident who had diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan showed the resident required assistance with ADLs, including two staff members for transfers and toileting and extensive assistance for dressing, bathing, grooming, and bed mobility. According to the facility’s incident report, the resident told an LPN that they had been raped by a CNA while receiving care. The resident later described that the CNA entered the room to change a wet brief, applied cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina while asking the CNA to stop. The CNA stated they provided incontinence care and applied A and D ointment to the perianal area, and the video review showed the CNA entered the room at 4:43 AM and exited at 5:19 AM. The resident’s family member reported that the resident called them, said to come immediately, and later stated that a staff member had raped them. The family member contacted law enforcement and requested hospital transfer. Facility leadership acknowledged awareness of the allegation but did not report the alleged rape to the Department of Health, stating they believed the allegation changed to rough handling and did not meet the reporting threshold. The DON, Administrator, and Social Worker each described differing understandings of the allegation and reporting status, and the report states there was no documented evidence that the allegation was reported to local law enforcement or the Department of Health within two hours as required.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure staff immediately reported allegations of abuse to administration for two separate resident-to-resident sexual abuse incidents involving three residents. One CNA witnessed Resident #3 inappropriately touch Resident #1’s breasts while Resident #1 was asleep, and later saw Resident #3 reach under Resident #2’s blanket while Resident #2 pushed the hands away and told Resident #3 to stop. The CNA redirected Resident #3 during both incidents but did not immediately notify the charge nurse, DON, or Administrator. The incidents were later identified by the DON through electronic medical record alerts, and the DON and Administrator stated they were not notified when the events occurred. The facility also failed to ensure staff immediately reported an injury of unknown origin for Resident #4. Two CNAs observed multiple bruises, including bruises resembling handprints, while providing care and notified an RN and LPN. The RN assessed the resident and documented bruising of unknown origin, but neither the RN nor the LPN notified the DON or Administrator at that time. The LPN stated the CNAs were discussing the bruises with the RN and therefore did not contact higher management, while the RN did not believe the bruising was concerning because the resident had fragile skin and was on a blood thinner. Because the allegations were not immediately escalated, the facility’s abuse investigation process was delayed, including resident assessment and collection of investigative information. For Resident #4, the DON stated the resident had already been transferred to the hospital before the facility initiated an abuse investigation and could not be assessed as part of the initial investigation. The Administrator acknowledged that facility protocol requiring immediate reporting of abuse allegations was not followed in both events.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported for one resident. A written statement from the resident said that a night shift CNA and the CNA’s helper slid the resident up in bed and rammed the resident’s head into the headboard, causing the resident to holler out in pain. The resident later stated that the staff had hurt them by being rough. An email statement from one CNA said that the resident’s head bumped the headboard while the resident was being pulled up in bed after a change, and that the CNA apologized and asked several times if the resident was okay. Employee counseling records showed two CNAs were terminated for failure to report an allegation of abuse. The administrator stated the abuse allegation and failure to report were substantiated after the facility investigation, and stated the staff should have reported the incident immediately when the resident said they were hurt.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the regulated timeframe for 2 of 27 residents reviewed for abuse. The facility policy stated that suspected abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately, defined as within 2 hours for allegations involving abuse or serious bodily injury, or within 24 hours for allegations that do not involve abuse or serious bodily injury. R15 was admitted with diagnoses including dementia, essential hypertension, depression, and pure hyperglyceridemia, and R14 was admitted with diagnoses including hypertension, left above-the-knee amputation, anxiety disorder, neurogenic bladder, and COPD. Staff interviews and record review showed that a nurse witnessed R14 touch R15 inappropriately in the dining room on 06/22/26, with the Social Services Director later stating the incident was reported to her on 06/24/26. The LPN stated she was told by an RN that R14 touched R15 inappropriately, separated the residents, discussed boundaries with R14, and did not report it because she thought the RN would report it to the DON. The DON stated she was made aware on 06/24/26 of an incident that had occurred a couple of nights earlier, and the Administrator stated the nurse assigned to the residents did not report the incident immediately.
Failure to Immediately Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported immediately to the Administrator when a CNA was witnessed using foul language at the bedside within earshot of a resident. The deficiency involved one resident reviewed for abuse/neglect and was based on interviews and record review showing that the allegation was not reported right away, but instead was brought to the DON hours later the same morning. The resident involved was a female with multiple serious diagnoses, including respiratory failure, a stage 2 sacral pressure ulcer, encephalopathy, anemia, diabetes, malnutrition, non-Alzheimer's dementia, depression, hypertension, severe chronic kidney disease, difficulty walking, failure to thrive, leukemia in remission, and a bone marrow transplant history. Her quarterly MDS showed a BIMS score of 07, indicating severe cognitive impairment, with delusions and inattentiveness. She was dependent on staff for personal hygiene, dressing, toileting, positioning, and transfers, was always incontinent of bowel and bladder, and received nutrition through a feeding tube. A CNA reported that while assisting the resident with care, another CNA repeatedly used disrespectful language toward the resident, including calling her a derogatory name while the resident was in the room and within hearing distance. The witness said she did not report the allegation immediately because she was thinking about it and did not want to jeopardize the other CNA's job, and she ultimately reported it later that morning to the DON. The DON and ADON confirmed the allegation was not brought to the Administrator until hours after it occurred, and the Administrator stated she was unaware of the behavior until the report was made. The facility records also showed policies requiring immediate reporting of suspected abuse and defining verbal abuse as communication within hearing distance that can cause humiliation, intimidation, fear, shame, agitation, or degradation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.