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F0609
D

Failure to Timely Report Alleged Abuse to Mandated Entities

Phoenix, Arizona Survey Completed on 11-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an allegation of abuse involving a resident was reported to mandated entities within the required 2-hour timeframe. The incident involved a resident with moderate cognitive impairment, who reported to a physical therapy assistant that a CNA had held a dirty brief close to her face during care, which the resident described as emotionally hurtful. The physical therapy assistant stated she reported the allegation to the DON within two hours of hearing it, but the facility's self-report to the State Agency was not submitted until the following day. Multiple staff interviews and documentation revealed inconsistencies regarding when the allegation was first reported and when the mandated reporting occurred. The DON and Administrator both stated that the report to authorities was made the same day the therapist brought the allegation forward, but time records and staff statements indicated that the incident was reported to the DON on one day and to the State Agency the next day. The facility's own investigation documents and interviews with involved staff confirmed that the initial report to the DON occurred on one date, but the mandated external reporting was delayed beyond the required 2-hour window. The resident involved had a history of moderate cognitive impairment and was admitted with multiple diagnoses, including malignant neoplasm of the colon and atrial fibrillation. The facility's policy required immediate reporting of suspected abuse to the administrator and mandated entities within two hours, but this protocol was not followed in this case. The delay in reporting could have impacted the timeliness and effectiveness of the investigation into the abuse allegation.

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