F0600

J

Failure to Immediately Protect Residents and Obtain RN Assessments After CNA Abuse

Auburn, New York Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement immediate protective measures and RN assessments after witnessed verbal and physical abuse by a CNA toward two residents. For the first resident, who had aphasia, hemiplegia, anxiety disorder, severely impaired cognition, limited range of motion, and required substantial to maximal assistance with ADLs, multiple CNAs reported that the resident became combative during care and that the assigned CNA handled the resident roughly and sprayed perfume on the resident while they were resisting care. One CNA reported seeing the perfume sprayed at the resident and hearing the abusive comment that another resident might “die on the commode,” made in front of this resident. Another CNA reported seeing the perfume sprayed over the resident’s body after care. The facility’s own investigation later characterized this as rough treatment and spraying cologne over the resident’s head and into their eyes while the resident tried to hit and push the CNA away.

Despite this information, the on-duty RN supervisor did not conduct or document an RN assessment of the first resident at the time of the incident. The CNA who witnessed the event reported it to the RN supervisor between approximately 4:00 PM and 4:45 PM, and the RN supervisor acknowledged being told that perfume had been sprayed and that the resident slapped the CNA away. The RN supervisor stated they did not believe abuse had occurred, did not interview the other CNA who wanted to report the incident, and did not complete or document a nursing assessment, although they recalled transporting the resident to the dining room and observing them as “fine and smiling.” The RN supervisor left at the end of their shift at 7:00 PM without escalating the concern as suspected abuse. The DON was not notified until approximately 7:49 PM by an LPN, and the CNA alleged to have committed the abuse was not suspended and removed from resident care until about 8:00 PM, several hours after the initial report.

The second resident involved had osteoarthritis, a knee replacement, Alzheimer’s disease, severely impaired cognition, used a wheelchair, had lower extremity impairment on one side, and was dependent for rolling and sit-to-stand and did not ambulate. During the same evening, the same CNA assigned to this resident was reported by another CNA and the resident’s roommate to have been verbally rude and curt, telling the resident they were not going to do the “up and down” with transfers all night, and to stay in bed. The assisting CNA described the CNA as rough when placing an arm under the resident’s arm and lifting the resident’s legs into bed, causing the resident to cry out in pain, and reported that the CNA leaned down toward the resident and repeated that they were tired of the “up and down game.” This was reported to an LPN, who spoke with the roommate and confirmed the account but did not consider it verbal abuse and did not report it to a supervisor. No RN assessment of the second resident was completed that evening, and the DON’s assessment was documented only on a later date without a time. The facility’s investigation later concluded that both physical and verbal abuse had occurred toward both residents, but at the time of the incidents, the CNA remained on duty with access to residents until being sent home around 8:00 PM, and no immediate RN assessments were documented for either resident.

Removal Plan

• All staff currently working in the facility (including staff who are employed by the hospital and work on the nursing home side) have been educated on Abuse, Identification of Abuse, and Reporting of Abuse.
• Provide education to any staff on leave prior to the start of their shift.