Failure to Timely Report Alleged Abuse and Submit Investigation Results
Penalty
Summary
The deficiency involves the facility’s failure to timely report alleged abuse incidents and to submit investigation results to the State Agency as required. Facility policy, last reviewed in January 2026, required any employee to immediately report suspected abuse, neglect, mistreatment, exploitation, or injuries of unknown origin to the Administrator and/or DON or the abuse hotline, and to report suspected crimes involving serious bodily injury, including criminal sexual abuse, immediately but no later than two hours after forming suspicion. For two residents with dementia, one with moderate cognitive impairment and one with severe cognitive impairment, an unwitnessed resident-to-resident altercation occurred at 6:15 PM and resulted in a small cut on one resident’s nose, possibly from being struck with a broken table by the other resident. This incident, which constituted resident-to-resident abuse, was not reported to the New York State Department of Health until the following afternoon at 3:53 PM, and the investigative report was not submitted until eleven days after the incident, exceeding the two-hour reporting requirement and the five-working-day timeframe for submission of investigation results. The facility also failed to report two separate allegations of staff-to-resident physical abuse to the State Agency. In one case, a resident with anxiety disorder, dementia, and severely impaired cognition for daily decision-making reportedly told a family member that an aide had hit them; a progress note documented that the DON was called for direction and the Administrator and Social Worker were emailed, and an internal investigation form recorded that the resident reported an aide was mean and struck them in the stomach, with abuse ultimately ruled out. In another case, a resident with dementia, aortic stenosis, and congestive heart failure, but intact cognition for daily decisions, reported that a nurse hit them; a facility investigative report documented that the investigation was completed with no evidence of abuse found. For both of these staff-to-resident abuse allegations, review of the iQIES system showed no submissions related to the incidents, indicating they were not reported to the New York State Department of Health. During interview, the Administrator stated that the previous DON had been responsible for submitting abuse reports, and acknowledged they were not aware that all allegations had to be reported within two hours even if unfounded, or that the complete investigation had to be submitted within five days of the allegation.
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