F0740

D

Failure to Update Behavioral Care Plans for Individualized Triggers and Behaviors

Scottsdale, Arizona Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to update and individualize behavioral health care plans to reflect known triggers and behaviors for two residents with severe cognitive impairment and significant psychiatric diagnoses. For one resident with parkinsonism, major depressive disorder, psychotic disorder, and anxiety disorder, the care plan initiated in November 2025 identified behaviors such as putting himself on the floor, hiding, refusing care, and making statements that no one was offering him anything. Interventions included medication administration, positive interaction, explaining why behavior was inappropriate, protecting others’ rights and safety, diverting attention, and removing the resident from situations. A Behavior IDT Review in February 2026 added general approaches for agitation, anxiety, or restlessness, such as calm approaches, guiding to a quiet safe space, and offering calming activities.

Despite these documented approaches, the resident had a known pattern of delusional accusations about others stealing his “four million dollars,” as described by staff interviews, and this behavior was associated with rapid escalation when he became agitated. An IDT note from February 13, 2026 documented that this resident accused another resident of stealing millions of dollars and punched that resident in the eye. Staff interviews confirmed that the resident frequently accused others of stealing his money and that this was a recurrent behavior, but the care plan and behavioral interventions were not updated to specifically address this individualized trigger or the associated risk of resident-to-resident altercations.

For the second resident, admitted with Alzheimer’s disease, dementia with agitation, personality change, major depressive disorder, and anxiety disorder, multiple behavior notes from July and November 2024 documented repeated incidents of taking other residents’ food and becoming combative or difficult to redirect. However, the behavioral treatment plan dated December 19, 2025 focused on sexually inappropriate and isolative behaviors, with known triggers of female staff assisting with care, and listed past behaviors such as elopement and exposing himself, without indicating a history of taking other residents’ food. A care plan focus initiated in December 2025 similarly addressed sexual inappropriateness, delusions, elopement risk, and self-isolation, with interventions such as cares in pairs and following the behavior plan, but did not include the documented pattern of taking other residents’ food or belongings. Staff interviews indicated that this resident would try to take items he wanted and that staff attempted redirection, yet these behaviors and triggers were not incorporated into the current care plan, contrary to the facility’s dementia clinical protocol requiring the IDT to identify and document the resident’s condition and needed supports and to review changes as they arise.