F0609

D

Missing Abuse and Misappropriation Investigation Records After Ownership Change

Mesa, Arizona Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that allegations of abuse, neglect, and misappropriation of resident property were properly documented and that related investigation records were available, as required by policy and regulation. Surveyors found that for 11 sampled residents, there were missing clinical records, care plans, nursing progress notes, and investigation reports associated with reported or alleged incidents. The facility repeatedly stated it was not in possession of requested records, including 5‑day investigation reports and self‑reports, for events that had been reported to the State Agency (SA) or were alleged by residents.

One resident was reportedly involved in an altercation with a nurse aide regarding loss of personal property, but the facility could not produce an investigation report or any clinical records for that individual and asserted that the resident had never resided there. Another resident had an allegation of misappropriation of funds by a payee, yet there was no care plan, nursing progress notes, or task documentation for the relevant time period in the EHR, and the facility reported it did not have those documents. In a separate resident‑to‑resident altercation, one resident with dementia and multiple psychiatric diagnoses remained in the facility, but the earliest nursing notes in the EHR were dated long after the alleged incident, and the facility could not provide the 5‑day report or records for the other resident allegedly involved, stating it did not possess those records.

Additional SA‑reported resident‑to‑resident altercations and misappropriation allegations were also not supported by contemporaneous documentation in the facility’s records. For two residents involved in a reported altercation, nursing progress notes only began more than a year after the incident, and no investigation report was available. For a resident with hypertension and cerebrovascular history, there was no care plan for the year of a reported misappropriation allegation and no progress notes or 5‑day report for the months surrounding the event. A resident with traumatic brain injury and psychiatric diagnoses reported being attacked by another resident, but the MDS and care plan for the relevant period were missing, and the facility could not provide requested progress notes or care plans for the months before and after the alleged event.

In another allegation, a resident reported that his roommate fondled his genitals; however, there was no documentation for the alleged roommate in the EHR, and the facility stated that person had never resided there. The resident’s own MDS and care plan did not cover the date of the alleged incident, and the earliest care plan and nursing notes were dated more than two years later. A separate resident who alleged misuse of insurance catalog benefits could not be located in the EHR at all, and the facility stated it did not have records if the resident or incident pre‑dated a change of ownership. The Medical Records Supervisor stated that medical records and incident/5‑day investigation reports should be retained for 10 years, and the Administrator confirmed there were no medical records or access to medical records, including 5‑day investigations and self‑reports, for residents prior to the change of ownership date. Facility policies required retention of resident health records for 10 years and facility investigations for 5 years, and required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and appropriate state and federal agencies, but the facility lacked the records to demonstrate compliance for the cited residents and events.