F0610

E

Failure to Timely Report, Remove Staff, and Review Video in Abuse Allegations

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to respond promptly and thoroughly to allegations of abuse and to protect residents from potential abuse. Facility policy required that all alleged abuse be immediately addressed, that any employee suspected of abuse be sent off duty until the investigation was complete, and that a safe environment be provided. In multiple instances, staff did not immediately report allegations to leadership, did not promptly remove the alleged perpetrators from resident care, and did not fully utilize available video surveillance as part of the initial investigations.

For one cognitively intact resident with diagnoses including anxiety, hypertension, and chronic pain, an investigation dated 02/20/2026 documented an allegation that an LPN placed hands in the resident’s face, pushed their head into a pillow, and cut their hair. The resident’s written statement indicated the staff member placed hands in front of their face and pushed their face and head into a pillow, and that after reporting this to another LPN, they were told the staff member would not return, but the staff member did re-enter the room and continued to provide care. The resident identified the LPN from photographs and was observed to be upset and anxious during the identification. The LPN who received the report documented that the resident voiced concerns during the night shift at 2:30 AM, but the allegation was not reported to leadership at that time, and the alleged LPN continued to provide care, including giving the resident a shower after the allegation was voiced.

For another resident with severe cognitive impairment and diagnoses including dementia, stroke, and COPD, an incident report documented that a CNA grabbed the resident and pushed them backward into a chair, causing a three-centimeter laceration to the left forearm. The incident occurred between approximately 1:30 AM and 1:45 AM, but the CNA was not immediately removed from resident care and remained on the unit providing care until later in the shift. A nurse manager reported witnessing the CNA grab the resident by the arms and push the resident into a chair, resulting in injury, and acknowledged the CNA should have been removed immediately. In both residents’ cases, video surveillance was available but was not reviewed as part of the initial investigations; for the first resident, video was only reviewed about five days later after surveyor inquiry and not all footage was reviewed, and for the second resident, video playback was not completed until several days later, also after surveyor inquiry, with the initial investigation lacking review of this available evidence.