Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Paradise Valley during CMS and state inspections, most recent first.
Two residents were found with medications left unsecured in their rooms, including prescribed inhalers and topical gel without current self-administration orders for one resident, and non-prescribed Lidocaine roll-ons brought from home and used for hip pain for another resident, with no corresponding provider orders or care plan interventions. Additionally, an LPN placed a dose of metronidazole in a medication cup on top of the medication cart and walked away, leaving it unattended. Staff and the DON later acknowledged that medications, including OTC products, are considered medications under facility policy and should not be left at the bedside or unattended, and that residents requesting self-administration must be assessed and have appropriate orders, but these practices were not followed in the observed instances.
A resident with an ESBL-producing E. coli hip wound infection had active orders and a care plan for contact isolation, with door signage and PPE available at the room entrance. During a lunch tray pass, a CNA entered the contact precaution room without performing hand hygiene or donning PPE, placed the meal tray on the bedside table, and allowed clothing to contact the bed linens before exiting and proceeding to handle another tray. In interviews, the CNA admitted PPE should have been used and acknowledged prior infection control training, while other staff and leadership confirmed that standard practice and facility policy require hand hygiene and appropriate PPE use for rooms under contact precautions.
Staff failed to clean and disinfect a mechanical lift and its sling after use with two residents, as observed during transfer events. CNAs were seen moving the lift and handling the unwiped sling without following cleaning protocols, despite facility policy and manufacturer instructions requiring disinfection after each use. Interviews with staff confirmed the deficiency.
A resident with intact cognition and multiple health conditions reported being verbally and physically abused by her sister during a visit. The incident was witnessed by a CNA and reported to an LPN, who was aware of previous verbal abuse but had not documented or reported it. The facility failed to implement its abuse prevention policy effectively, as staff did not report or document the abuse until after the physical incident occurred.
A resident with COPD and respiratory failure experienced significant delays in discharge due to the facility's failure to coordinate transportation and DME orders, including home oxygen equipment. Despite the resident's and family's wishes to transfer to an ALF, the facility did not adequately follow through on essential tasks, leading to the resident remaining in the facility beyond the planned discharge date.
A resident's advance directives were inconsistently documented, with conflicting indications of CPR and DNR preferences. Despite the resident's intact cognition and clear preferences, the care plan and provider orders did not align, leading to potential non-compliance with the resident's wishes. Staff interviews highlighted a lack of proper documentation and adherence to facility policy regarding advance directive changes.
A facility failed to implement a care plan intervention for monitoring medication side effects for a resident prescribed Ativan. Despite the care plan's requirement to observe and report adverse reactions, monitoring was not documented from June 13 to June 24, even though the medication was administered 10 times. The DON confirmed the lapse, which could result in unmet care needs.
A resident with multiple medical conditions experienced significant weight loss, but the facility failed to revise the care plan to include specific nutritional goals. Despite severe cognitive impairment and refusal of supplements, the care plan lacked targeted interventions. Interviews with staff revealed the care plan did not address the resident's weight loss effectively.
An OT at the facility lacked valid CPR and First Aid certifications, with the last certification expiring in 2012. The Payroll Coordinator and DON were under the impression that such certifications were not required for PT/OT staff, contrary to CMS guidelines and facility policies that mandate current CPR certification for healthcare providers.
A resident with severe cognitive impairment was prescribed Ativan for anxiety, with orders to monitor for side effects. However, from June 13 to June 24, 2024, there was no documentation of side effects monitoring, despite the medication being administered 10 times. Interviews with an LPN and the DON confirmed the lack of documentation, which could lead to unidentified adverse reactions.
A resident with dementia was subjected to undignified treatment by a visitor who accused him of inappropriate behavior without evidence. The visitor yelled and threatened the resident, causing distress, despite staff confirming the resident was not involved. The facility's failure to protect the resident's dignity and rights led to a deficiency.
A resident with COPD and respiratory failure was found using an empty oxygen tank despite having continuous oxygen orders. The CNA admitted past occurrences of empty tanks, and the DON stated this did not meet facility expectations. The facility's policy emphasized the importance of adhering to physician orders for medication administration.
The facility failed to prevent verbal abuse between two residents with behavioral issues. One resident, with a history of aggressive comments, made derogatory remarks about another's appearance, leading to a verbal altercation. Despite care plans and interventions, the situation escalated, requiring staff intervention and a psychiatric evaluation for one resident. Staff interviews revealed awareness of abuse types but indicated a gap in preventing such incidents.
The facility failed to implement enhanced barrier precautions, as required by their policy and CDC recommendations, for residents with wounds or indwelling medical devices. Observations revealed no PPE or signage outside resident rooms, and interviews with staff confirmed the facility's decision not to use enhanced barrier precautions, citing confusion among staff.
The facility failed to notify the family of a resident with severe cognitive impairment about the resident's COVID-19 diagnosis, despite the facility's policy requiring such communication. Interviews with staff confirmed that this was an oversight.
The facility failed to prevent abuse when a resident with Alzheimer's was found being hit by his roommate, who has dementia and a history of aggressive behavior. The incident occurred after the victim urinated on the floor, leading to frustration and aggression from the roommate. Staff interviews and facility policies indicate that the protocol for handling such incidents involves ensuring resident safety and immediate reporting, but these measures were not effectively implemented.
The facility failed to update care plans for two residents following significant incidents of aggression and threats, despite a history of such behaviors and the facility's policies requiring updates to care plans to mitigate future conflicts.
The facility failed to provide a resident with a high risk of falls with a floor mat as specified in their care plan. Despite the resident's history of Alzheimer's, dementia, and repeated falls, staff were unaware of the requirement, and the mat was not in place, leading to preventable accidents.
The facility failed to retain a resident's medical record for the required six-year period, as mandated by State law. The records were destroyed prematurely, and the facility's policy on Document Management was not followed, leading to the potential inaccessibility of pertinent clinical information.
Unsecured Medications in Resident Rooms and on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were securely stored and not left unattended at residents’ bedsides or on top of the medication cart. For one resident with chronic obstructive pulmonary disease, atrial fibrillation, and pneumonia, surveyors observed a prescribed Breztri inhaler and a tube of Voltaren gel on the resident’s vanity sink area, and an albuterol inhaler at the bedside. The resident stated that the nurse must have forgotten to take the Breztri inhaler and Voltaren gel and that the inhaler stays on the bedside table in case it is needed. A registered nurse confirmed that the resident only had a physician’s order for self-administration of a Ventolin rescue inhaler and did not have a current order for self-administration of the Breztri inhaler or Voltaren gel, and acknowledged that medications should not be left at the bedside. A second resident, admitted with chronic obstructive pulmonary disease, abdominal aortic aneurysm without rupture, unsteadiness on feet, difficulty in walking, and generalized muscle weakness, was found to have two Lidocaine roll-on bottles on the vanity sink area. This resident, who had intact cognition per the MDS, reported bringing the Lidocaine roll-ons at admission, keeping them at the sink, and using them since admission. The resident also stated that staff had applied the Lidocaine to the hip for pain but could not recall which staff had done so. Review of provider orders and the care plan showed no evidence of prescribed Lidocaine roll-ons or care plan interventions for their use, although the care plan did include a focus on left hip pain with interventions for pain medications as ordered. In addition to unsecured medications in resident rooms, surveyors observed a medication security lapse during a medication pass. An LPN removed metronidazole 500 mg from the medication cart, placed it in a medication cup, and left the cup unattended on top of the medication cart while walking down the hall toward a resident’s room with her back to the cart. No residents were observed passing the cart at that time. In subsequent interviews, the LPN acknowledged that leaving medications unattended created a risk that someone could access medications that were not theirs, and the DON confirmed that the facility’s expectation is that no medications should be left unattended and that medications should be stored in a safe place or taken with the nurse when stepping away. Facility policies reviewed by surveyors stated that medications are to be administered safely and appropriately per physician order and that residents requesting to self-administer medications must be assessed by the interdisciplinary team to determine if self-administration is safe. Interviews with nursing staff and the DON further described the facility’s stated processes and expectations for self-administration of medications, including assessing residents for safety and cognitive ability, obtaining provider orders, documenting self-administration on the MAR, and implementing safety measures to prevent other residents from accessing medications in resident rooms. Staff also described that over-the-counter products such as Tylenol, stool softeners, and Lidocaine roll-ons are considered medications and identified risks associated with medications being left at the bedside or otherwise unsecured. Despite these stated processes and expectations, the observations of unsecured prescribed medications in one resident’s room, non-prescribed Lidocaine roll-ons in another resident’s room, and unattended medication on top of the medication cart demonstrate that medications were not consistently stored in locked compartments or otherwise kept secure as required by facility policy and professional standards.
Failure to Follow Contact Isolation Precautions During Meal Tray Delivery
Penalty
Summary
The deficiency involves a failure to follow contact isolation precautions for a resident with an ESBL-producing E. coli hip wound infection. The resident was admitted with diagnoses including prosthesis, subsequent encounter, aftercare following joint replacement surgery, and systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction. A physician order dated February 11, 2026, required contact isolation precautions every shift related to the ESBL E. coli hip wound infection, and the care plan initiated on February 12, 2026, identified the resident as receiving IV medications for this infection with an intervention for use of contact isolation. The admission MDS documented an active diagnosis of infection/inflammatory reaction due to an internal hip prosthesis, subsequent encounter. During a lunch tray pass observation on February 17, 2026, a CNA entered the resident’s contact precaution room without performing hand hygiene or donning PPE, despite PPE and contact precaution signage being present at the room entrance. The CNA took the lunch tray from the cart, entered the room, and placed it on the bedside table, leaning in such a way that his clothing came into contact with the resident’s bed linens, then exited the room and proceeded to reach for another tray. When questioned, the CNA acknowledged that PPE should have been used, stated he was confused because he usually worked on another hall, and confirmed he had received infection control training and understood that not donning PPE could transfer germs to other residents. Other staff interviews, including with another CNA, the Infection Preventionist, and the DON, confirmed that staff are informed of residents on precautions via report and door signage and are expected to perform hand hygiene, don PPE before entering, and remove PPE and perform hand hygiene upon exiting rooms under contact precautions, consistent with the facility’s written Contact Precautions policy.
Failure to Clean and Disinfect Mechanical Lift After Resident Use
Penalty
Summary
Facility staff failed to clean and disinfect a mechanical lift and its sling after resident use, as observed during two separate transfer events. Certified Nursing Assistants (CNAs) were seen rolling the mechanical lift to the end of the hallway without performing any cleaning or disinfection after use. In one instance, a CNA picked up an unwiped sling with bare hands and carried it down the hall, leaving it exposed to the air. These actions were directly observed and confirmed by staff interviews, where CNAs acknowledged that the equipment was not cleaned after use and recognized the importance of proper cleaning to prevent infection. Interviews with the Unit Manager and the Director of Nursing confirmed that facility policy and manufacturer instructions require cleaning and disinfecting the mechanical lift and accessories after each use and before storage. Facility documentation, including the mechanical lift user manual and relevant policies, specify that equipment must be cleaned with soap and water or a hard surface disinfectant prior to storage and before use on another resident. Despite these clear guidelines, staff did not follow the required procedures, resulting in a failure to maintain infection prevention and control standards.
Failure to Protect Resident from Family Member Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a family member. The resident, who had intact cognition and was admitted with conditions including a fracture, chronic kidney disease, and rheumatoid arthritis, reported being verbally and physically abused by her sister during a visit. The incident was witnessed by a CNA who heard yelling and derogatory remarks directed at the resident. The CNA reported the incident to an LPN, who confirmed the resident's account of being slapped and verbally abused. The LPN, who was aware of previous arguments between the resident and the family member, did not report or document these prior incidents. The resident expressed that the family member frequently raised her voice and used derogatory language, which had been reported to the LPN before. Despite the resident's complaints, no action was taken to address the ongoing verbal abuse until the physical incident occurred. The Social Services Director was informed of the incident and noted the resident's stress due to the situation. The facility's policy on abuse prevention was not effectively implemented, as staff failed to report and document the abuse, and the family member was not restricted from visiting until after the incident. The facility's administrator emphasized the importance of reporting any abuse, but the staff did not adhere to these expectations.
Failure to Coordinate Discharge Plan for Resident
Penalty
Summary
The facility failed to ensure a discharge plan based on the assessed needs and goals was in place for a resident with chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and heart failure. The resident, who was oxygen-dependent and used a CPAP at night, expressed a desire to return home, but the family requested a transfer to an assisted living facility (ALF). Despite the resident's and family's wishes, the facility did not adequately coordinate the discharge process, leading to significant delays. The social services director (SSD) communicated with the assisted living facility and the resident's family, but there was a lack of follow-through on essential tasks such as setting up transportation and durable medical equipment (DME) orders, including home oxygen equipment. The SSD incorrectly assumed that the accepting facility was responsible for arranging transportation, while the long-term care insurance indicated it was the discharging facility's responsibility. Additionally, there was no evidence that the SSD sent the necessary DME referral for the home oxygen equipment to the approved vendor, resulting in further delays. Despite multiple communications and requests from the assisted living facility and the resident's family, the facility did not confirm the DME and transportation arrangements. The resident remained in the facility beyond the planned discharge date, leading to the assisted living facility releasing the reserved apartment. The resident expressed frustration and distress over the prolonged discharge process, and the SSD acknowledged the failure to realize the barrier to discharge was due to the DME provider not accepting the oxygen test on the form submitted. The facility's policy required documentation of discussions with the resident or their representative for resident-initiated discharges, which was not adequately followed in this case.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's choice regarding advance directives was accurately reflected in the medical record. The resident, who was admitted with diagnoses including acute kidney failure, pneumonitis, anxiety, and depression, had expressed a desire for CPR in the event of cardiac arrest on multiple occasions. However, there was inconsistency in the documentation, as one advance directive form indicated a DNR preference, while the care plan and provider order recap reflected a full code status. This inconsistency could lead to the resident's choices not being followed. Interviews with staff revealed a lack of clarity and proper documentation regarding the resident's advance directives. An LPN acknowledged the discrepancy and noted the absence of a DNR order or paper versions of the advance directive. The facility's policy required immediate charting and notification of the physician for any changes in advance directives, but this was not adhered to, resulting in the potential for staff to not follow the resident's most recent advance directive choice.
Failure to Monitor Medication Side Effects
Penalty
Summary
The facility failed to implement a care plan intervention for monitoring medication side effects for a resident who was prescribed an antianxiety medication, Ativan. The resident, who had severe cognitive impairment and was diagnosed with dementia, Alzheimer's disease, cerebral infarction, mild neurocognitive disorder, and altered mental status, was admitted with a physician's order to monitor for side effects related to the use of anti-anxiety medications. The care plan, revised on January 18, 2024, included interventions to observe for target behaviors and report any adverse reactions. However, the monitoring for side effects was not documented as completed from June 13 to June 24, 2024, despite the medication being administered on 10 occasions during this period. The Director of Nursing confirmed during an interview that the monitoring for side effects was not implemented as care planned. The facility's policy on comprehensive care plans emphasizes the importance of timely and person-centered care plans, involving an interdisciplinary team and the resident or their representative. The failure to monitor the resident for side effects as per the care plan could result in the resident not receiving the necessary care and services to meet their needs.
Failure to Revise Care Plan for Resident's Nutritional Needs
Penalty
Summary
The facility failed to revise a care plan to include resident-specific nutritional goals for a resident with multiple medical conditions, including acute metabolic acidosis, type 2 diabetes mellitus, unspecified protein-calorie malnutrition, anemia, dysphagia, and chronic kidney disease. The resident was admitted with a weight of 130 lbs and experienced significant weight loss over a short period. Despite the resident's severe cognitive impairment and refusal of supplements due to taste, the care plan did not include specific goals or desired outcomes related to nutrition and weight loss. The resident's weight decreased from 130 lbs to 115 lbs over several weeks, with documentation indicating inadequate meal consumption and refusal of supplements. The care plan was revised to include interventions such as providing supplements, but it lacked specific goals addressing the resident's nutritional needs and weight loss. The facility's policy required care plans to be reviewed and revised by an interdisciplinary team, but this was not adequately done for the resident in question. Interviews with facility staff, including the Registered Dietician and Director of Nursing, revealed that the care plan did not have resident-specific goals related to the resident's continued weight loss. The facility's policy emphasized the importance of timely and person-centered care plans, but the care plan for this resident did not reflect changes in the resident's condition or address the significant weight loss effectively.
OT Lacks Valid CPR and First Aid Certifications
Penalty
Summary
The facility failed to ensure that an occupational therapist (OT) had valid Cardiopulmonary Resuscitation (CPR) and first aid certifications. A review of the personnel file for the OT revealed that the CPR or First Aid certification had expired on February 28, 2012. During an interview, the Payroll Coordinator stated that there was no evidence of any valid CPR or First Aid certifications for the OT and believed that such certifications were only required for nurses and nurse aides, not for Physical Therapy (PT) or OT staff. Further interviews revealed that the Director of Nursing (DON) was informed by the Director of Rehabilitation that CPR and First Aid certifications were no longer required for PT or OT staff. However, the Centers for Medicare & Medicaid Services (CMS) guidelines require staff to maintain current CPR certification for healthcare providers, which includes hands-on practice and in-person skills assessment. The facility's policies also state that care should be coordinated and consistent with specialized rehabilitative services provided by qualified personnel, and that staff should have the appropriate competencies and skills to assure resident safety and maintain the highest level of care.
Failure to Monitor Side Effects of Psychotropic Medication
Penalty
Summary
The facility failed to adequately monitor for side effects related to the use of a psychotropic medication, Ativan, for a resident diagnosed with dementia, Alzheimer's disease, cerebral infarction, mild neurocognitive disorder, and altered mental status. The resident was prescribed Ativan to manage anxiety as evidenced by restlessness, with orders to monitor for side effects. However, from June 13 to June 24, 2024, there was no documentation of side effects monitoring, despite the medication being administered on 10 occasions during this period. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the lack of documentation for side effects monitoring. Both staff members acknowledged that monitoring should have been conducted and documented, as per the facility's policy on psychotropic medication use. The absence of monitoring documentation could result in unidentified adverse reactions, potentially affecting the resident's overall care.
Visitor's Aggressive Behavior Violates Resident's Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect by a visitor, leading to a deficiency in resident rights. Resident #25, who was admitted with diagnoses including dementia and hemiplegia, was involved in an incident where a visitor of another resident (#392) yelled and cursed at him. The visitor accused Resident #25 of inappropriate behavior towards Resident #392, although staff interviews and observations indicated that Resident #25 was not near Resident #392 and was simply reading in the day room. The incident occurred when the visitor noticed that Resident #392's clothing was disheveled, with her breasts exposed, and assumed that Resident #25 was responsible. However, staff members, including a Registered Nurse and a Certified Nursing Assistant, confirmed that Resident #25 was sitting at a distance and was not involved in any inappropriate actions. The visitor's aggressive behavior, including threats to throw Resident #25 out of the window, was witnessed by multiple staff members, who intervened to de-escalate the situation and ensure the safety of Resident #25. Interviews with staff and the resident revealed that Resident #25 was confused and scared by the incident, and expressed feelings of unsafety and distress. The facility's policies on dignity, resident rights, and abuse prevention emphasize the importance of treating residents with respect and protecting them from abuse, including from visitors. The failure to uphold these policies in this instance resulted in a deficiency related to the resident's right to a dignified existence and self-determination.
Failure to Maintain Oxygen Supply for Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on supplemental oxygen did not have an empty oxygen tank while in use. The resident, who had been admitted with chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute and chronic respiratory failure with hypoxia, and heart failure, was observed in the activity room with a nasal cannula connected to an empty oxygen tank. The care plan for the resident included continuous oxygen therapy as per medical doctor orders, with a specific physician order for oxygen at 2 liters per minute, which could be titrated to 4 liters to maintain 88% saturation. During an interview, a Certified Nursing Assistant (CNA) acknowledged that the oxygen tank for the resident had been empty in the past and stated that monitoring the gauge was necessary to prevent this. The Director of Nursing (DON) confirmed that using an empty oxygen tank for a resident with continuous oxygen orders did not meet the facility's expectations and emphasized the importance of staff checking the resident's oxygen throughout the shift. The facility's policy on medication administration highlighted the need for safe and appropriate administration per physician orders, including ensuring the right time and frequency, assessment, and evaluation of medications.
Failure to Prevent Verbal Abuse Between Residents
Penalty
Summary
The facility failed to protect two residents from verbal abuse, as evidenced by an incident involving residents with a history of behavioral issues. Resident #10, diagnosed with Major Depressive Disorder and Adjustment Disorder, had a care plan noting aggressive-like behaviors and verbal comments about others' appearances. Despite interventions to observe and intervene in interactions, an incident occurred where Resident #10 made derogatory comments about another resident's appearance, leading to a verbal altercation with Resident #17. Resident #17, with diagnoses including schizoaffective disorder and bipolar disorder, had a care plan addressing verbal aggression and thoughts of self-harm. On the day of the incident, Resident #17 reacted aggressively to Resident #10's comments, threatening physical harm. The staff intervened by separating the residents and consulting a medical doctor, who recommended a psychiatric evaluation for Resident #17. Interviews with staff and residents revealed awareness of the potential for verbal abuse and the need for immediate reporting and intervention. The facility's policy, reviewed prior to the incident, emphasized the prevention of all types of abuse. However, the incident highlighted a failure to effectively implement these measures, as both residents engaged in verbal abuse despite existing care plans and interventions. Staff interviews indicated a general understanding of abuse types and reporting procedures, but the incident suggests a gap in preventing resident-to-resident verbal abuse.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure transmission-based precautions, particularly enhanced barrier precautions, were in place to prevent the development or transmission of infections. During an observation of care for a resident with a feeding tube, wound, and catheter, no transmission-based precaution signage or personal protective equipment (PPE) was found outside or near the room entrance. Interviews with the Assistant Director of Nursing/Infection Preventionist and the Director of Nursing revealed that the facility does not use enhanced barrier precautions, citing confusion among staff as the reason. This decision contradicts the facility's policy and CDC recommendations, which require enhanced barrier precautions for residents with wounds or indwelling medical devices. Further observations of the entire facility revealed no PPE or enhanced barrier signage present at any resident room with G Tubes/J Tubes, wounds, colostomy, nephrostomy, catheter, or multi-drug-resistant organisms (MDRO). The Executive Administrator confirmed that the management team has access to facility policies and expects them to be followed. The facility's policy on transmission-based precautions and isolation procedures mandates the use of enhanced barrier precautions and appropriate signage to prevent the spread of infections, which was not adhered to in this case.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure communication was provided to the family when a resident had a change of condition. Resident #369, who was admitted with multiple diagnoses including cardiac arrhythmia, Parkinson's disease, bradycardia, unspecified dementia with behavioral disturbance, anorexia, and major depressive disorder, was diagnosed with COVID-19. Despite the facility's policy requiring notification of the resident's family or responsible party in the event of a change in condition, there was no evidence that the family was informed of the resident's COVID-19 diagnosis. The resident had a severe cognitive impairment, as indicated by a BIMS score of 03, and required extensive assistance with activities of daily living. Interviews with the Social Services Director and the Director of Nursing revealed that nursing staff were responsible for notifying families of changes in condition, and this should be done within the same shift. However, it was acknowledged that there was an oversight in notifying the resident's spouse about the COVID-19 diagnosis. The facility's policy on changes in residents' condition or status mandates immediate notification of the resident's primary care provider and the resident's representative, but this protocol was not followed in this instance.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse by another resident. Resident #520, who has Alzheimer's disease and dementia, was found by a CNA being hit multiple times by his roommate, Resident #525. Resident #520 was assessed as severely cognitively impaired and had difficulty communicating his needs as he only spoke Spanish. The incident occurred after Resident #520 urinated on the floor, which upset Resident #525. Although no visual injuries were noted, Resident #520 verbalized pain and was given pain medication. Resident #525 was removed from the room to ensure safety. Resident #525, who has unspecified dementia, psychotic disturbance, anxiety, and major depressive disorder, admitted to hitting his roommate out of frustration. The clinical record revealed no prior physical altercations but noted two verbal altercations. The facility's investigation report confirmed the incident and documented that Resident #525 had a history of aggressive behaviors. The facility's policy mandates that residents involved in altercations be separated and that incidents be reported and investigated immediately. Interviews with staff members, including a CNA, an LPN, and the DON, indicated that the facility's protocol for handling abuse allegations involves ensuring resident safety, reporting to supervisors, and conducting thorough investigations. The facility's policies on abuse prevention and protection emphasize the importance of separating residents involved in altercations and implementing interventions to ensure the safety of all residents. Despite these policies, the facility failed to prevent the abuse of Resident #520 by Resident #525.
Failure to Update Care Plans Following Resident Altercations
Penalty
Summary
The facility failed to ensure that the care plans for two residents were updated and revised as needed following significant incidents. Resident #525, who was admitted with diagnoses including unspecified dementia and major depressive disorder, was involved in a physical altercation with his roommate. Despite a history of verbal altercations, the care plan was not updated to address the resident's aggressive behavior and risk for future altercations. No interventions were put in place to mitigate further incidents, even though the resident admitted to having aggressive behaviors in the past and the nurse practitioner indicated that psychiatric follow-up was needed. Similarly, Resident #535, who was admitted with schizoaffective disorder and bipolar disorder, threatened to kill her roommate. Despite the resident's history of verbal behavior symptoms and manipulative behavior, the care plan was not updated to address the risk for resident-to-resident altercations. The Director of Nursing confirmed that the expectation is to update care plans following such incidents, but this was not done. The facility's policies on comprehensive care plans and abuse prevention were not followed, leading to a failure in addressing and mitigating potential conflicts between residents.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident with a high risk of falls was provided with a floor mat as specified in their care plan. Resident #333, who has a history of Alzheimer's disease, dementia, and repeated falls, was observed without a floor mat in their room despite the care plan indicating its necessity. The resident had multiple falls documented, including an incident where the resident was found on the floor in the dayroom, resulting in a skin tear. Staff interviews revealed that the CNA and LPN assigned to the resident were not aware of the requirement for a floor mat, and it was not in place at the time of observation. The facility's policy on fall management requires assessment and implementation of appropriate interventions to minimize fall risks. However, the lack of communication and adherence to the care plan led to the resident not having the necessary fall prevention measures in place. The LPN later retrieved a floor mat for the resident, indicating a lapse in the consistent application of the care plan and fall prevention strategies. This deficiency could result in preventable accidents such as falls, as evidenced by the resident's repeated falls and the absence of the prescribed floor mat.
Failure to Retain Medical Records as Required by State Law
Penalty
Summary
The facility failed to retain the medical record for a resident as required by State law. A complaint was submitted by the resident on September 30, 2018, and the facility's documentation revealed that the records for this resident had been destroyed before the required six-year retention period. The facility's policy on Document Management, revised in March 2023, stated that records must be retained for six years after the date of the patient's discharge. However, the facility's letter dated January 18, 2024, indicated that the oldest records retained off-site were from 2019, which means the records for the resident in question were destroyed prematurely. An interview with the administrator confirmed that the facility transitioned to Electronic Medical Records in 2019 and did not store any records onsite before this transition. The facility's policy also included that the facility is responsible for monitoring the retention of documents. This failure to retain the medical records as required by State law could result in pertinent clinical information not being accessible when needed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgecrest Post Acute | 0.2 mi | ★★★★★ | 2 | 0 |
| Phoenix Mountain Post Acute | 2.6 mi | ★★★★★ | 6 | 0 |
| Acacia Health Center | 3 mi | ★★★★★ | 3 | 0 |
| Arizona State Veteran Home-phx | 4.1 mi | ★★★★★ | 2 | 0 |
| Vi At Grayhawk, A Vi And Plaza Companies Community | 5 mi | ★★★★★ | 0 | 0 |
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