Failure to Timely Report Suspected Narcotic Diversion and Abuse to State Agency
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse, specifically suspected narcotic diversion and medication tampering, to the State Agency within 2 hours as required by facility policy. During a shift-change narcotic count on the 300 medication cart, an agency RN questioned the appearance of one resident’s oxycodone 5 mg blister card, noting that cavity #59 was secured with regular medical tape and that the back of the blister pack appeared tampered with. Further inspection showed that while tablet #59 appeared consistent with oxycodone 5 mg, the remaining tablets in the card had different physical characteristics, and each blister cavity on the back had been covered with small pieces of paper tape. Upon removal and inspection, staff determined that all tablets except #59 had been replaced with a different medication that appeared consistent with loratadine. Following this discovery, nursing staff conducted a review and recount of all narcotic cards on the medication cart and identified additional oxycodone 5 mg and 10 mg blister cards that appeared to have been tampered with in a similar manner. A total of seven blister cards were ultimately identified as affected, with 279 narcotic tablets missing and replaced with other medications, including loratadine and over-the-counter pink Vitamin B-12 tablets. The affected residents had documented chronic pain and opioid orders: one resident with Parkinson’s disease, spinal fusion, and spondylosis had an oxycodone 5 mg PRN order; another resident with COPD, heart failure, renal failure, low back pain, and chronic pain had oxycodone 5 mg PRN for breakthrough pain; a hospice resident with emphysema, heart failure, renal failure, dementia, schizophrenia, PTSD, and spondylosis had oxycodone 5 mg PRN; another resident with stroke, emphysema, a left heel pressure ulcer, and pain had both scheduled and PRN oxycodone 5 mg; and a resident with paraplegia, renal failure, neurogenic bladder, anxiety, depression, bipolar disorder, and chronic pain syndrome had oxycodone 10 mg PRN for severe pain. At the time of surveyor observation in April, the affected residents generally reported their pain as controlled and denied unmanaged pain in the preceding months, and the blister cards then present in the cart did not appear tampered with. The facility’s internal documentation shows that the suspected diversion and tampering were reported to the DON by a staff RN at 6:21 a.m. on March 4, 2026, and the DON contacted the Administrator at 6:27 a.m. that same morning. However, the allegation was not successfully reported to the State Agency within 2 hours. A State Agency complaint intake print screen shows the reporting party as the Administrator, with awareness of the missing medication incident at 6:10 a.m. on March 4, 2026, and a submission date of 11:21 a.m. on March 5, 2026. The Administrator stated he attempted to report the incident on March 4 but did not complete the submission correctly due to user error and did not realize it had not been saved until he returned the next morning and resubmitted it. The facility’s Abuse, Neglect and Exploitation policy requires that all alleged violations involving abuse or resulting in serious bodily injury be reported to the Administrator, State Agency, Adult Protective Services, and other required agencies immediately, but not later than 2 hours after the allegation is made. The surveyors determined that the facility failed to meet this requirement when it did not report the suspected abuse (medication diversion and misappropriation) to the State Agency within the required 2-hour timeframe. The survey findings further detail the scope of the tampering identified in the facility’s medication diversion matrix. One resident’s oxycodone 5 mg card had 59 tablets missing or replaced; another resident had two oxycodone 5 mg cards with a total of 70 tablets missing or replaced; a hospice resident had one oxycodone 5 mg card with 11 tablets missing or replaced; another resident had one oxycodone 5 mg card with 55 tablets missing or replaced; and a resident with chronic pain syndrome had two oxycodone 10 mg cards with 84 tablets missing or replaced. The physical description of the tampering was consistent across cards, with paper tape precisely placed over each blister bubble and the original narcotic tablets replaced by non-narcotic medications. Despite the facility’s internal recognition of this as medication diversion and suspected abuse on the morning it was discovered, the external reporting to the State Agency was not completed within the 2-hour window specified by the facility’s own abuse, neglect, and exploitation policy, leading to the cited deficiency. Resident assessments and care plans documented that these residents were on scheduled and/or PRN opioid regimens for chronic pain and other serious conditions, and the MDS assessments showed varying levels of cognitive function, from no impairment to mild impairment. During the surveyor interviews in April, the residents involved generally denied uncontrolled or increased pain in the prior months and reported that their pain was well managed. Nonetheless, the deficiency centers on the facility’s failure to adhere to its mandated reporting procedures for alleged abuse, specifically the delayed reporting of suspected narcotic diversion and misappropriation of resident medications to the State Agency within the required 2-hour timeframe after the allegation was made.
Penalty
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Failure to report an alleged misappropriation of resident funds. A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident took it, but the SSD reportedly said it was too long ago to investigate. The CNO recalled hearing about missing funds from a family member but did not pursue it, and the CEO stated the allegation should have been reported to the State Agency.
Failure to report alleged sexual abuse within required timeframe. A resident with intact cognition and significant ADL dependence alleged that a CNA raped them during incontinence care; the resident later described possible penetration and burning, while the CNA said they only provided brief care and applied ointment. The family member contacted law enforcement and requested hospital transfer, but facility leadership did not report the allegation to DOH within 2 hours, stating they believed the allegation had changed to rough handling and did not meet the reporting threshold.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin: Staff did not immediately report two resident-to-resident sexual abuse incidents involving one resident touching two others, and staff also did not immediately report bruising of unknown origin on another resident. A CNA redirected the resident during the abuse incidents but did not notify the charge nurse, DON, or Administrator, and an RN and LPN did not escalate the bruising after assessing it and hearing it described as handprint-like. The delayed reporting prevented timely initiation of the abuse investigation process and resident assessment.
Failure to Report Alleged Physical Abuse: A resident alleged that two CNAs were rough while repositioning them in bed and that the resident’s head was bumped into the headboard, causing pain. One CNA confirmed the head bump occurred during care, and the administrator stated the abuse allegation and failure to report were substantiated because the staff did not report the incident immediately.
Failure to Timely Report Allegation of Abuse: A nurse witnessed one resident touch another resident inappropriately, but the incident was not reported within the required timeframe. The LPN separated the residents and addressed boundaries with the resident involved, but did not report the event because she believed the RN would notify the DON. The DON and Administrator later stated the incident had not been reported immediately as required.
Failure to Immediately Report Verbal Abuse Allegation: A CNA was heard using foul and disrespectful language toward a cognitively impaired resident during care, but the allegation was not reported immediately to the DON/Administrator. The witness delayed reporting for several hours, and the DON, ADON, and Administrator confirmed the report was not made until later that morning. The resident had severe cognitive impairment, was dependent on staff for care, and received nutrition via GT.
Failure to Report Alleged Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was reported to the State Agency as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months before the survey, he reported $1,600.00 missing to the Social Services Director and believed another resident had taken the money. He reported that the SSD asked how long ago it happened, and when he said about one and a half months earlier, he was told it had been too long ago to investigate. During the survey, the SSD did not respond to a call for interview, the CNO stated she recalled a family member mentioning the missing funds but did not ask further questions, and the CNO said the allegation was never made directly to her or facility staff. The CEO stated the allegation should have been reported to the State Agency.
Failure to Report Alleged Sexual Abuse Within Required Timeframe
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse was reported to the New York State Department of Health and local law enforcement within two hours of the allegation. The deficiency involved one resident who had diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan showed the resident required assistance with ADLs, including two staff members for transfers and toileting and extensive assistance for dressing, bathing, grooming, and bed mobility. According to the facility’s incident report, the resident told an LPN that they had been raped by a CNA while receiving care. The resident later described that the CNA entered the room to change a wet brief, applied cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina while asking the CNA to stop. The CNA stated they provided incontinence care and applied A and D ointment to the perianal area, and the video review showed the CNA entered the room at 4:43 AM and exited at 5:19 AM. The resident’s family member reported that the resident called them, said to come immediately, and later stated that a staff member had raped them. The family member contacted law enforcement and requested hospital transfer. Facility leadership acknowledged awareness of the allegation but did not report the alleged rape to the Department of Health, stating they believed the allegation changed to rough handling and did not meet the reporting threshold. The DON, Administrator, and Social Worker each described differing understandings of the allegation and reporting status, and the report states there was no documented evidence that the allegation was reported to local law enforcement or the Department of Health within two hours as required.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure staff immediately reported allegations of abuse to administration for two separate resident-to-resident sexual abuse incidents involving three residents. One CNA witnessed Resident #3 inappropriately touch Resident #1’s breasts while Resident #1 was asleep, and later saw Resident #3 reach under Resident #2’s blanket while Resident #2 pushed the hands away and told Resident #3 to stop. The CNA redirected Resident #3 during both incidents but did not immediately notify the charge nurse, DON, or Administrator. The incidents were later identified by the DON through electronic medical record alerts, and the DON and Administrator stated they were not notified when the events occurred. The facility also failed to ensure staff immediately reported an injury of unknown origin for Resident #4. Two CNAs observed multiple bruises, including bruises resembling handprints, while providing care and notified an RN and LPN. The RN assessed the resident and documented bruising of unknown origin, but neither the RN nor the LPN notified the DON or Administrator at that time. The LPN stated the CNAs were discussing the bruises with the RN and therefore did not contact higher management, while the RN did not believe the bruising was concerning because the resident had fragile skin and was on a blood thinner. Because the allegations were not immediately escalated, the facility’s abuse investigation process was delayed, including resident assessment and collection of investigative information. For Resident #4, the DON stated the resident had already been transferred to the hospital before the facility initiated an abuse investigation and could not be assessed as part of the initial investigation. The Administrator acknowledged that facility protocol requiring immediate reporting of abuse allegations was not followed in both events.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported for one resident. A written statement from the resident said that a night shift CNA and the CNA’s helper slid the resident up in bed and rammed the resident’s head into the headboard, causing the resident to holler out in pain. The resident later stated that the staff had hurt them by being rough. An email statement from one CNA said that the resident’s head bumped the headboard while the resident was being pulled up in bed after a change, and that the CNA apologized and asked several times if the resident was okay. Employee counseling records showed two CNAs were terminated for failure to report an allegation of abuse. The administrator stated the abuse allegation and failure to report were substantiated after the facility investigation, and stated the staff should have reported the incident immediately when the resident said they were hurt.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the regulated timeframe for 2 of 27 residents reviewed for abuse. The facility policy stated that suspected abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately, defined as within 2 hours for allegations involving abuse or serious bodily injury, or within 24 hours for allegations that do not involve abuse or serious bodily injury. R15 was admitted with diagnoses including dementia, essential hypertension, depression, and pure hyperglyceridemia, and R14 was admitted with diagnoses including hypertension, left above-the-knee amputation, anxiety disorder, neurogenic bladder, and COPD. Staff interviews and record review showed that a nurse witnessed R14 touch R15 inappropriately in the dining room on 06/22/26, with the Social Services Director later stating the incident was reported to her on 06/24/26. The LPN stated she was told by an RN that R14 touched R15 inappropriately, separated the residents, discussed boundaries with R14, and did not report it because she thought the RN would report it to the DON. The DON stated she was made aware on 06/24/26 of an incident that had occurred a couple of nights earlier, and the Administrator stated the nurse assigned to the residents did not report the incident immediately.
Failure to Immediately Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported immediately to the Administrator when a CNA was witnessed using foul language at the bedside within earshot of a resident. The deficiency involved one resident reviewed for abuse/neglect and was based on interviews and record review showing that the allegation was not reported right away, but instead was brought to the DON hours later the same morning. The resident involved was a female with multiple serious diagnoses, including respiratory failure, a stage 2 sacral pressure ulcer, encephalopathy, anemia, diabetes, malnutrition, non-Alzheimer's dementia, depression, hypertension, severe chronic kidney disease, difficulty walking, failure to thrive, leukemia in remission, and a bone marrow transplant history. Her quarterly MDS showed a BIMS score of 07, indicating severe cognitive impairment, with delusions and inattentiveness. She was dependent on staff for personal hygiene, dressing, toileting, positioning, and transfers, was always incontinent of bowel and bladder, and received nutrition through a feeding tube. A CNA reported that while assisting the resident with care, another CNA repeatedly used disrespectful language toward the resident, including calling her a derogatory name while the resident was in the room and within hearing distance. The witness said she did not report the allegation immediately because she was thinking about it and did not want to jeopardize the other CNA's job, and she ultimately reported it later that morning to the DON. The DON and ADON confirmed the allegation was not brought to the Administrator until hours after it occurred, and the Administrator stated she was unaware of the behavior until the report was made. The facility records also showed policies requiring immediate reporting of suspected abuse and defining verbal abuse as communication within hearing distance that can cause humiliation, intimidation, fear, shame, agitation, or degradation.
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