F0610

F

Failure to Investigate and Report Alleged Abuse, Falls, and Injuries of Unknown Origin

Rensselaer, New York Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate, protect residents during, and properly report multiple allegations and incidents of potential abuse, neglect, falls, and injuries of unknown origin. Facility policy required immediate reporting of suspected abuse, mistreatment, neglect, exploitation, or misappropriation of property to the New York State Department of Health (NYSDOH) and facility leadership, initiation of an investigation coordinated by the DON, immediate actions to prevent further potential abuse, completion of RN and psychosocial assessments, and suspension of any accused staff member pending investigation. Surveyors found that for several residents, there was no documented evidence that these steps were followed, and key staff interviews confirmed that expected processes were not consistently carried out.

For two residents involved in a resident-to-resident altercation, the facility lacked documentation of an investigation into a reported verbal and physical incident in which one resident entered another resident’s room at night, allegedly harassed them, and struck them with a water bottle. The resident who reported being assaulted told a family member they felt shaky and scared whenever they saw the other resident and did not feel safe with that resident remaining on the same floor. The grievance form documenting this allegation was incomplete: the staff recipient’s name/signature was blank, the section asking whether further investigation was required was left blank, and there was no documented investigation or follow-up narrative. There was also no evidence that the incident was reported to NYSDOH, and the care plans for both residents did not include abuse/neglect interventions related to this event.

Another deficiency involved a resident who reported being hurt by a CNA, where the facility did not initiate an immediate investigation or measures to prevent further potential abuse at the time of the report. As a result, the accused staff member was not identified when the allegation was made and continued to provide care to residents. For additional residents with multiple falls and an injury of unknown origin, including several unwitnessed falls and a hip fracture discovered after reports of acute hip pain and functional decline, there was no documented evidence of thorough investigations. In one case, an unwitnessed fall with head lacerations and a second fall with a larger scalp laceration requiring hospital treatment were not supported by complete Accident and Incident Reports, RN assessments, or staff and resident statements. The hip fracture was also not accompanied by an Accident and Incident Report or investigation to rule out possible abuse or neglect. Interviews with nursing and medical staff revealed uncertainty and inconsistency regarding who initiated and completed Accident and Incident Reports and investigations, and the Medical Director reported not having seen or signed any such reports in recent months, despite expecting investigations and reporting for injuries of unknown origin and falls.

Additional interviews with facility leadership and clinical staff confirmed that the expected processes for incident/accident reporting and investigation were not followed. A nurse manager stated they were not notified of the resident-to-resident altercation until a later family meeting and did not conduct any staff interviews or investigation. The assistant administrator, medical director, DON, and administrator each stated they would have expected immediate reporting of resident-to-resident altercations, completion of incident/accident reports, and thorough investigations, including interviews and documentation, but acknowledged these did not occur in the cited cases. Staff also reported that turnover and vacant positions contributed to incident and accident reporting not occurring as it should have, and the acting DON was unsure how Incident and Accident Reports were being completed. Collectively, these findings show that the facility did not ensure all alleged violations and injuries of unknown origin were thoroughly investigated, that residents were protected from further potential abuse or neglect during investigations, and that results were reported to the administrator and State Survey Agency within required timeframes.