F0607

D

Failure to Report and Investigate Allegation of Staff-to-Resident Abuse and Neglect

Mesa, Arizona Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse and neglect reporting policy after an allegation of staff-to-resident abuse and neglect involving Resident #70. Resident #70 had multiple significant diagnoses, including hemiplegia and hemiparesis, protein-calorie malnutrition, facial weakness, dysphagia, muscle weakness, aphasia following cerebral infarction, cognitive, social, or emotional deficit, frontal lobe and executive function deficit, atrial fibrillation, hydrocephalus, convulsions, and headache. An admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that the resident had exhibited rejecting care behaviors. A care plan initiated in late December identified the resident as being at risk for alteration in psychosocial well-being due to staff failure to honor resident choices during care.

On December 27, 2025, the Executive Director (ED) documented a Concern & Comment Form after the resident stated he felt neglected because he had been left in a wet brief for a few hours and requested that law enforcement be called for neglect. The form noted that the concern was reported to the ED and that the ED spoke with the resident and his wife that afternoon. The resident and his wife reported that he did not receive care upon arrival from the hospital. The ED’s handwritten investigation notes concluded the same day that the resident had received care throughout the night, including at arrival, at midnight, and when the nurse checked his feeding pump. The ED documented that the concern was resolved at the time it was shared and that the investigation findings were concluded within about 40 minutes.

In a later interview, the resident’s wife reported that during the night in question, an RN and a CNA responded to the resident’s call light for a brief change after he spilled his bedside urinal, and that they turned him back and forth aggressively during the brief change despite his request for them to stop. She stated that the RN made a comment to the assisting staff that they needed to get out of the room or else the resident would get them fired, and that staff then ignored the resident for the rest of the night and left his bed remote out of reach. She also stated that two police reports had been filed regarding abuse and neglect during his stay, and that the incident from December 27, 2025, was not reported by the facility to any state agency except the police. The ED confirmed in interview that he was informed of the wife’s allegation of neglect on December 27, that he spoke with both the wife and the resident, and that because the resident contradicted the wife’s allegation, he decided not to report the incident to the State Survey Agency, APS, or other required entities, despite facility policy requiring that all alleged violations be reported.

Staff interviews further described the events and the facility’s handling of the allegation. The RN identified as being involved stated that she did not recall any allegation of abuse, neglect, or rough care being made to her or against her, and denied ignoring the resident or making the statement about staff being fired. A CNA who assisted with care that night reported that the resident had a history of making allegations and that he received two-person care at all times; she described assisting with a full bed change after the resident spilled his urinal and later being contacted by the previous DON to write a statement after the resident reported that night shift had neglected him. Another CNA stated she was instructed to provide care in pairs because the resident was having issues with staff and reporting that no care was being given. Despite these multiple accounts and the wife’s explicit allegation of neglect, the ED acknowledged that he did not report the December 27 allegation to state agencies, relying instead on his own assessment that the incident was not abuse or neglect.

Review of the facility’s policies showed that abuse included the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and that neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The reporting policy required that all alleged violations be reported immediately, but no later than 2 hours if abuse or serious bodily injury was involved, or within 24 hours if not, to the administrator and to other officials, including the State Survey Agency and APS. The policy also specified that an individual reporting an alleged violation did not need to label it as abuse or neglect for it to trigger a facility investigation and reporting, and that all alleged violations, whether oral or written, must be reported to the administrator and other officials in accordance with state law. Despite this, the ED stated that he did not report the December 27 allegation to any state agency because he did not deem it necessary after the resident contradicted his wife’s account, thereby failing to follow the facility’s abuse and neglect reporting policy for this allegation.