F0610

D

Failure to Investigate and Document Multiple Abuse and Misappropriation Allegations

Mesa, Arizona Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate and maintain documentation for multiple allegations of abuse, neglect, and misappropriation of property as required by its own abuse prevention policy. For one resident who allegedly accused a nurse aide of loss of personal property, state agency records showed the resident had been admitted to the facility, but the facility denied the resident had ever resided there and could not provide a five-day investigation report or any clinical records. In another case involving an alleged misappropriation of funds by a resident’s payee, the facility’s EHR contained no care plan, nursing progress notes, or task records for the relevant time period, and the facility stated it did not possess the requested records, preventing confirmation that the allegation was investigated.

Additional deficiencies were identified in several resident-to-resident altercations and other abuse-related complaints. In one incident, a resident reportedly struck another resident’s hand in the dining room; staff stated the residents were separated and an investigation was conducted, but the facility could not produce a five-day investigation report or nursing documentation for the time of the incident. One of the involved residents did not appear in the EHR at all, and the facility reported having no documentation for that resident. In another altercation, a resident was observed striking another resident on the shoulder, but there were no nursing progress notes for either resident for the time frame of the incident, and the facility could not provide an investigation report.

Further, the facility lacked documentation for allegations of misappropriation of financial resources, physical attacks by other residents, and inappropriate sexual contact between roommates. For one resident alleging misappropriation of financial resources, there was no care plan for the year of the allegation and no nursing progress notes until nearly two years later, and the facility could not provide investigation reports or contemporaneous records. For another resident who reported being physically attacked by another resident, the MDS and care plans for the relevant period were unavailable. In a complaint of inappropriate sexual contact, the alleged perpetrator did not appear in the EHR and the facility stated that person had never resided there, while the complainant’s MDS, care plan, and nursing notes for the time of the allegation were missing. In an additional case of alleged misuse of insurance benefits, the facility had no records for the resident and stated it did not possess information for residents or incidents prior to a change of ownership.

Interviews with the Administrator and the Medical Records Supervisor confirmed that the facility did not have access to medical records, incident reports, or five-day investigation reports for residents prior to a change of ownership, despite the Medical Records Supervisor stating that such records should be retained for ten years following discharge. Both acknowledged that no paper records existed for residents prior to the ownership change and that this absence resulted in a lack of resident history and incomplete understanding of residents’ needs. Review of the facility’s abuse prevention policy showed that all allegations of abuse, neglect, misappropriation, and exploitation were to be promptly reported, thoroughly investigated, and fully documented, but the facility’s inability to produce investigation reports and contemporaneous clinical documentation for the cited residents demonstrated noncompliance with this policy.