F0610

E

Failure to Maintain and Document Thorough Investigations of Abuse Allegations

Scottsdale, Arizona Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of abuse. For the first resident, an individual admitted with a displaced intertrochanteric fracture of the left femur, osteoporosis, and chronic pain had an ADL care plan indicating risk for self-care performance deficits and encouragement to participate in care. This resident experienced a fall in the facility bathroom, was found on the floor by the toilet, and was documented as alert and oriented and able to verbalize what happened. Later that same day, documentation showed the resident expressed unhappiness with the facility without elaborating. A late entry incident note then recorded that the resident reported being treated roughly and refused further care from a CNA who had worked the morning shift, with a skin assessment showing no new findings.

The facility’s initial report to the State Agency documented that the resident told an unnamed therapist he did not want care from a CNA assigned that day and alleged that this CNA had caused at least three broken bones, was going to kill him, and was out to get him. The resident provided a physical description of the CNA, including age range, hair color, glasses, tattoos, and clothing, and later clarified the clothing color and tattoo location, which the facility noted matched a specific CNA. The resident further alleged that the CNA wheeled him too fast, bumped his feet on walls, made him feel like a horse while being showered, and that during turning for care he hit his face on the wall. The CNA was immediately suspended, and the facility reported that it was contacting other agencies. Despite these detailed allegations, review of the clinical record and facility documentation revealed no evidence that the facility conducted or maintained a thorough investigation into this abuse allegation.

The second resident involved was admitted with diagnoses including chronic embolism, hemiplegia and hemiparesis, restless leg syndrome, and other specified brain disorders, and had an ADL care plan noting risk for self-care performance deficits with interventions to praise self-care efforts and encourage participation. A health status note documented that this resident was alert and oriented, and a late entry NP note indicated a long history of daily smoking. Psychology progress notes on two consecutive days stated that observations and conversations with the resident showed no evidence of psychological harm related to an incident the prior week, but did not describe the incident itself, only noting no concerns or changes and no further conflicts. The facility’s initial report to the State Agency later specified that the resident had reported to the ED that another resident made sexual comments toward her while she was sitting on the smoking patio. As with the first case, review of the clinical record and facility documentation showed no evidence that this allegation of abuse was thoroughly investigated.

Interviews with facility leadership and review of facility policies further clarified the deficiency. The DON stated she did not know where the investigations related to these two residents were and referred to them as being "outside the guideline," explaining that this meant outside the facility’s document retention timeframes. The administrator similarly stated he could not find any evidence of investigations for these incidents and cited a facility memo on record retention that limited how long incident reports, self-reports, and grievances were kept. The DON also described the facility’s abuse policy and the expected process for responding to abuse allegations, including ensuring resident safety, suspending involved staff, reporting to the abuse coordinator and external agencies within required timeframes, and conducting interviews with the victim, alleged perpetrator, and witnesses. However, despite these stated procedures and policies emphasizing identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation, there was no documentation available to demonstrate that thorough investigations were completed or maintained for the abuse allegations involving these two residents.