F0609

E

Failure to Report Resident-to-Resident Altercations to State Agency

Syracuse, New York Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The facility failed to report resident-to-resident altercations to the New York State Department of Health (NYSDOH) as required by state regulations and its own policies. Facility policy on Reporting and Monitoring Accidents and Incidents, revised in 09/2024 and again in 05/2025, required the DON, ADON, Director of Investigations or designee to review all incidents for alleged abuse, mistreatment, neglect, injury of unknown origin, or elopement, and to report such incidents immediately to Administration. State guidance in DAL NH 22-20 and CMS memo QSO-22-19-NH required nursing homes to submit an initial incident report and a final Investigation Summary Report to NYSDOH within five days of an incident involving reportable events such as abuse, neglect, mistreatment, exploitation, misappropriation, injury of unknown origin, elopement, and certain deaths. Despite these requirements, the facility did not submit required reports for two separate resident-to-resident altercations involving one resident.

Resident #1, who had Alzheimer’s disease and bipolar disorder with psychotic features and was documented as having moderately impaired cognition and no behavioral symptoms during the 10/02/2025 MDS assessment period, was involved in two incidents. On 09/10/2025, a RN Supervisor’s progress note documented that Resident #1 threw coffee on staff, striking another resident seated at the table, then refused to discuss the behavior and used excessive profanity toward staff and residents; there was no incident report or evidence this event was reported to NYSDOH. On 09/30/2025, an incident report and attached investigative summary documented that Resident #1 hit another resident on the cheek, causing light redness, after the other resident attempted to remove food from Resident #1’s plate; there was no documented evidence this altercation was reported to NYSDOH. In interviews, the DON stated the 09/10/2025 coffee incident was considered incidental and not reported because the coffee was cold and the other resident was not injured, and the 09/30/2025 altercation was not reported because there was no injury, pain, or mental anguish noted. The Administrator stated they became aware of incidents through internal processes and were involved when there was an incident report for resident-to-resident abuse, but there was no indication that these two incidents were reported externally as required.