F0600

E

Failure to Prevent Repeated Resident‑to‑Resident Physical Abuse

Scottsdale, Arizona Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from resident‑to‑resident physical abuse, despite known behavioral histories and documented patterns of aggression, delusions, and boundary violations. Multiple residents with dementia, psychotic disorders, mood disorders, and severe cognitive impairment were involved in separate altercations in which one resident physically struck, grabbed, or otherwise assaulted another. In several cases, residents had documented histories of intrusive wandering, delusions, sexually inappropriate behavior, or prior physical altercations, yet these behaviors were not consistently reflected in care plans as physical aggression risks, and preemptive interventions to prevent contact or escalation were not clearly implemented. Staff and leadership interviews repeatedly described the facility as a “behavioral facility” with unpredictable behaviors and acknowledged frequent resident‑to‑resident altercations.

In one incident, a resident with dementia, severe cognitive impairment, and a history of entering other residents’ rooms reported being punched in the nose by another resident who had a personality disorder, anxiety, and a documented pattern of making false accusations, going into other residents’ rooms, and breaking their belongings. Another incident involved a resident with severe cognitive impairment and Alzheimer’s disease who was found with a purple/blue bruise under the eye after reporting that his roommate, a resident with parkinsonism, psychotic disorder, and severe cognitive impairment, punched him while accusing him of stealing millions of dollars. The facility’s investigation initially concluded that this event did not happen and later characterized it as an accident, despite an IDT note documenting that the punch occurred. In a separate case, a resident with severe cognitive impairment and bipolar and depressive disorders had his wrist grabbed and squeezed hard by another resident with dementia and severe cognitive impairment, who was described as trying to be helpful by pulling him away from automatic doors.

Additional altercations included a resident with severe cognitive impairment and a history of physical aggression toward staff and others being kicked multiple times in the thigh by another resident with schizoaffective disorder, dementia with agitation, and a prior documented assault on another resident and threats toward a nurse. Staff interviews indicated that this resident became verbally and physically aggressive when frustrated, such as when needs for cigarettes, beverages, or television viewing were not met, and that another resident’s wandering likely triggered the kicking incident. Another event involved a resident with vascular dementia, anxiety disorder, violent behavior, and prior involvement in a physical altercation punching a cognitively impaired resident in the stomach after the latter attempted to help push his wheelchair, despite the aggressor’s known intolerance of being touched. In yet another case, a resident with Alzheimer’s disease, dementia with agitation, and a history of taking others’ food and becoming combative during redirection admitted to hitting his moderately cognitively impaired roommate in the head to take his blanket because he was cold. Across these events, the facility’s own abuse policy stated that residents have the right to be free from abuse, including physical abuse, yet residents repeatedly experienced physical contact and assaults from other residents.