F0600

D

Failure to Protect Residents From Abuse and Neglect by CNA and Inadequate Investigation of Injuries

Troy, New York Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent abuse, neglect, or mistreatment of residents and to adequately investigate and respond to incidents involving a CNA’s handling of residents. The facility’s Abuse & Neglect Policy, updated on 04/03/2025, stated that residents had the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation, and involuntary seclusion. Despite this policy, an abbreviated survey found that two of four residents reviewed for abuse, neglect, or mistreatment were not protected from willful infliction of abuse, neglect, or mistreatment. The facility did not fully investigate an incident on 08/02/2025 in which CNA #1 lowered Resident #1 to the floor, and later-obtained video footage showed abusive handling and the resident being left on the floor unattended for several minutes.

Resident #1 had diagnoses including Parkinson’s disease with dyskinesia and fluctuations, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. An MDS dated 08/08/2025 documented that this resident could understand and be understood and had intact cognition for decisions of daily living. An incident report dated 08/02/2025 documented CNA #1’s account that the resident stood in their room, was assisted into a wheelchair, and, while being taken from the room, grabbed the wall handrail and lifted themselves up, prompting the CNA to lower the resident to the floor to prevent a fall. However, video footage from 08/02/2025 showed CNA #1 entering the resident’s room without knocking, pulling the resident into the wheelchair despite resistance, repeating the maneuver with a near fall, and then moving the wheelchair backward while the resident attempted to block the wheel with their foot. The footage showed the resident standing and falling to the floor on their side, after which CNA #1 gestured toward the resident, walked away, and left the resident on the floor alone for approximately two minutes before returning briefly with a mechanical lift and then leaving again. The resident remained on the floor for about four minutes total before a nurse arrived, and the review of the video concluded that CNA #1 neglected the resident by walking away after the fall.

Resident #3 had diagnoses of unspecified dementia with other behavioral disturbances, hypothyroidism, and major depressive disorder. An MDS documented that this resident was usually able to understand others, was usually understood, and was severely cognitively impaired. The care plan indicated the resident required one-person assistance for bed mobility and ADLs and had a history of hitting and screaming at staff and resisting care, with interventions such as allowing time to de-escalate, reapproaching if refusing care, and placing a soft object in the resident’s hands if combative. An incident report dated 08/01/2025 documented a blue/gray bruise on the resident’s nose, with contributing factors listed as poor safety awareness, dementia, ill-fitting glasses, an unpadded wall, and resting their head on a table when fatigued. However, the ADON documented that CNA #1 had previously provided personal care and turned this resident in a way that caused them to hit their face on the wall, causing injury. The facility attributed the injury to environmental and resident factors and did not treat the event as potential abuse, instead viewing CNA #1 as needing more education on bed mobility.

The facility’s broader investigation, dated 08/15/2025 through 09/03/2025, showed that CNA #1 was suspended after being possibly responsible for multiple injuries on more than one resident in their care assignments. On 07/19/2025, a bruise and abrasion on Resident #2’s forehead were attributed to rough handling during bed mobility. On 08/01/2025, bruising on the right side of Resident #3’s face and around the eye and nose was attributed to another CNA rolling the resident into the wall and to ill-fitting glasses. On 08/15/2025, bruising on Resident #4’s neck, appearing multiple days old, was attributed to the resident being resistive to care. Interviews with nursing leadership and staff showed that, at the time of the incidents, they did not suspect abuse by CNA #1, did not immediately remove the CNA from resident care, and did not fully investigate the events as potential abuse or neglect until a pattern of injuries and video review prompted further scrutiny. The DON and ADON acknowledged that the actions captured on video were not acceptable and that leaving a resident unattended on the floor for multiple minutes was not appropriate, but these acknowledgments occurred after the events that led to the deficiency.

Interviews also revealed gaps in immediate reporting and investigation. CNA #1 stated they gave a verbal statement on the day of Resident #1’s fall but were unable to enter a written statement into the computer and that no written statement was taken from them at that time. LPN #4 reported being told by CNA #1 that the resident had been ambulating when they were not supposed to and did not suspect the explanation was inaccurate, despite the later video evidence. The ADON described that if there had been any indication from Resident #1 of an issue with CNA #1, they would have handled the situation differently, such as interviewing the staff member privately or changing assignments, but this did not occur at the time. The DON and Administrator described that video footage was typically reviewed only for certain types of incidents, such as falls with injuries or resident-to-resident issues, and that no staff raised concerns about CNA #1 until the DON began questioning employees. These actions and inactions contributed to the failure to protect residents from abuse and neglect and to promptly and thoroughly investigate potential mistreatment as required by regulation.