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F0609
D

Failure to Timely Report Alleged Abuse to State Authorities

Spring Valley, New York Survey Completed on 10-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all alleged violations of abuse were reported immediately, but not later than two hours, to the New York State Department of Health for one of three residents reviewed for abuse. On 9/23/2025 at approximately 2:00 PM, a family member reported that a resident alleged sexual abuse. However, the allegation was not reported to the Department of Health until 9/24/2025 at 11:18 AM, exceeding the required reporting timeframe outlined in the facility's Abuse Prevention Policy and Procedure. The policy mandates that all alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made, if the events involve abuse or result in serious bodily injury. The resident involved had diagnoses including anxiety disorder, depression, and hypertension, and was documented as having intact cognition with behavioral symptoms that significantly intruded on others and put the resident at risk. During interviews, the DON and Administrator acknowledged awareness of the two-hour reporting requirement but stated that the allegation was not reported within the required timeframe because it was considered vague and confusing, and the resident had a history of accusations. The facility conducted an internal investigation within two hours and concluded that abuse did not occur, which contributed to the delay in reporting the allegation to the Department of Health.

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