F0609

D

Failure to Report Allegation of Visitor Abuse to Authorities

Mesa, Arizona Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The facility failed to report an allegation of abuse to the state agency involving a resident with severe cognitive impairment. The resident had multiple diagnoses, including a femoral neck fracture, generalized muscle weakness, dysphagia, difficulty walking, cognitive communication deficit, protein-calorie malnutrition, epilepsy, chronic kidney disease, vascular dementia, depression, and hypertension. Her care plan addressed impaired cognitive function and thought processes related to dementia, with interventions focused on communication at her level of understanding. MDS assessments showed BIMS scores of 7 and 9, indicating severe to moderate cognitive impairment, which affected her decision-making and ability to assess personal safety.

On one evening, a CNA observed the resident’s friend assisting with feeding and flicking the resident’s nose in an aggressive manner. The CNA instructed the visitor to stop, after which the visitor approached and yelled at the CNA. The CNA reported the incident to an RN, who documented the event and stated she reported it to the DON. The DON stated he went to the facility, interviewed the resident, and, after discussing the situation with the Abuse Coordinator/Administrator, concluded there were no aspects of abuse or neglect and did not report the allegation to the appropriate authorities. The Abuse Coordinator confirmed awareness of the allegation and agreed with the decision not to report. Review of the electronic health record and grievance log showed no evidence that the allegation was reported or that a grievance was filed, despite a facility policy requiring immediate removal of visitors involved in such allegations and reporting to law enforcement and applicable federal or state agencies within required timeframes.