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F0600
G

Staff-to-Resident Physical and Verbal Abuse Incident

Buffalo, New York Survey Completed on 12-31-2025

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

On 12/08/2025, a certified nurse aide (CNA) was observed on video surveillance striking a resident in the face, resulting in a red mark on the resident's cheek. The incident occurred after the resident, who had a history of alcoholic cirrhosis, chronic kidney disease, and chronic obstructive pulmonary disease, became agitated and attempted to self-transfer from a recliner. The resident, who was moderately cognitively impaired and known to display verbal and physical aggression, struck the CNA during an attempt to reposition them. In response, the CNA grabbed the resident's wrist and slapped them in the face. The CNA was also witnessed using profane language directed at the resident during the altercation. Multiple staff interviews confirmed the sequence of events, with several staff members hearing or witnessing the slap and the use of inappropriate language. The CNA admitted to reacting physically after being struck by the resident and acknowledged that their response was inappropriate. The incident was immediately reported by the CNA to the supervising nurse, and the resident was subsequently assessed for injuries. The red mark on the resident's cheek resolved by the following day, and no additional injuries or changes in behavior were documented in the days following the incident. The facility's abuse prevention policy defined physical abuse as the willful infliction of injury, including hitting and slapping. The investigation concluded that physical abuse had occurred, as the CNA's actions met the definition of abuse. The incident was corroborated by video evidence and staff interviews, which consistently described the CNA's response as unacceptable and constituting physical and verbal abuse. The resident was monitored for psychosocial harm, and although no lasting injury or behavioral changes were documented, the event was determined to have caused psychosocial harm according to the reasonable person concept.

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