Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse to the New York State Department of Health as required by regulation and by its own Abuse Prohibition policy. The policy, last revised on 09/11/2025, states that all alleged violations involving abuse, neglect, exploitation, or resident property are to be reported immediately, but not later than two hours after the allegation is made. Despite this, an allegation that a certified nursing assistant (CNA) was rough handed and hit a resident on the buttock was not reported to the State Survey Agency or other required authorities. Resident #1 had diagnoses including non-Alzheimer’s dementia, muscle weakness, and difficulty walking, and a Minimum Data Set dated 01/02/2025 documented severely impaired cognition. On 02/17/2026, surveillance video showed Resident #1 ambulating with an unsteady gait, holding onto hallway handrails, then moving a personal protective equipment cart into other residents’ rooms. CNA #1, who had been wheeling another resident up the hallway, followed Resident #1 into a room, pulled the resident by the arm into the hallway, then held the resident under the left armpit and pulled them up the hallway toward their wheelchair while the resident resisted. CNA #1 then seated Resident #1 on the edge of the wheelchair; as the resident resisted, CNA #1 held the resident under the left armpit, placed a hand behind the resident holding them by the pants, dragged the resident back into the wheelchair, and pushed and held the resident’s upper body forward while moving a hand back and forth at the resident’s lower back, during which the resident’s body jerked forward. At approximately 5:30 PM that day, Resident #2’s visitor reported to the Director of Nursing that they had observed CNA #1 being rough handed and hitting Resident #1 on the buttock. The facility’s internal summary of the incident documented that the visitor came to the DON’s office demanding discipline for CNA #1 after a verbal altercation and reported hearing a commotion, then observing CNA #1 attending to Resident #1 and questioning what the CNA was doing. A registered nurse supervisor assessed Resident #1 the same day, noting the resident was smiling, in good spirits, had no visible injury, and reported no pain or discomfort. The Assistant Administrator later stated that, after reviewing the video, they concluded there was no harm and no allegation of rough handling or hitting, and therefore the incident was not treated as an abuse allegation and was not reported to the Department of Health, despite the visitor’s report and the facility’s policy requirements.
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