F0609

D

Failure to Timely Report Alleged Physical Abuse and Investigation Results

Stamford, New York Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The facility failed to ensure timely reporting of an alleged abuse incident and the results of the subsequent investigation, as required by regulation and facility policy. Facility policy, revised in January 2025, required that any alleged violations involving mistreatment, neglect, or abuse, including serious injuries of unknown source, be reported immediately to the Administrator/Designee, DON/Designee, or department director, and that suspected resident abuse involving physical injury be reported to the New York State Department of Health (NYSDOH) no later than two hours after the allegation. The policy also required submission of the Electronic Incident Reporting form to NYSDOH within 24 hours of occurrence/discovery and mandated that the results of the investigation be reported to the relevant authorities within five business days of the incident.

Resident #125, who had metabolic encephalopathy, cerebral infarction, right-sided hemiplegia, moderate cognitive impairment, and was usually able to understand and be understood, reported to a CNA on 2/05/2024 at 11:35 AM that an LPN had shoved them in the chest the prior evening. This allegation of physical abuse was not reported to NYSDOH until 7:01 PM that same day, exceeding the two-hour reporting requirement for suspected abuse involving physical injury. Additionally, the investigation report was not submitted to NYSDOH until 2/13/2024, which was beyond the required five working days from the date of the incident. During an interview, the Administrator stated that subsequent interviews led the resident to report that the nurse did not touch them and a witness confirmed this, and acknowledged not recalling why the reporting was not completed within the required time frames.