Citations in Arizona
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Arizona.
Statistics for Arizona (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Arizona
Two residents with cognitive and behavioral health issues were involved in a physical altercation in the dining room when one became agitated and physically confronted the other, resulting in a nosebleed. The incident occurred without staff present in the dining area, as staff were occupied elsewhere, allowing the altercation to escalate before intervention. The facility's failure to provide adequate supervision and prevent abuse was substantiated by staff interviews and clinical records.
A resident with moderate cognitive impairment and a history of unsafe wandering and exit-seeking behaviors was able to leave a locked dementia unit undetected, despite door alarms and staff presence. The resident was found outside the facility, having tipped his wheelchair and sustained a knee injury while attempting to evade staff, resulting in hospital evaluation. Staff interviews and observations confirmed that monitoring and supervision were inadequate to prevent this avoidable accident.
A resident with complex medical needs had antihypertensive medication held on two occasions due to low blood pressure, but the provider was not notified as required. Additionally, vital signs were not obtained or documented prior to the resident's transfer to the hospital, contrary to facility policy. Staff interviews and record review confirmed these omissions.
A resident was admitted with a bruise and reported concerns about a neighbor, leading to an allegation of physical abuse. Although the facility notified internal leadership and later reported the incident to APS and the Ombudsman, there was no evidence that law enforcement was notified as required by policy. Staff interviews revealed uncertainty about whether police had been contacted, and the care plan was not updated promptly to address the risk. The facility did not follow its own procedures for immediate reporting of suspected abuse.
A resident with severe cognitive impairment and on anticoagulant therapy was found with multiple unexplained injuries, including a head abrasion and lip injury. Although the facility documented the injuries and notified family and medical staff, there was no evidence that the required report was made to the state agency. Staff interviews and policy review confirmed that such incidents should be reported, but the facility did not follow its own procedures or regulatory requirements.
A resident with dementia and on anticoagulant therapy was transferred to the hospital after a family member noticed a bruise and called 911. Only a face sheet was provided during the transfer, and the required documentation, including relevant diagnoses and medical information, was not sent with the resident. Staff interviews revealed a lack of awareness about required transfer documents, and the facility's policy for emergency transfers was not followed.
A resident with cognitive and behavioral health diagnoses was forcibly removed from bed and given a shower by an RN and a CNA, despite repeated refusals and vocal objections. The incident was witnessed and reported by another CNA, and interviews confirmed that the resident was physically handled against her will. Both staff members involved had prior disciplinary actions and had completed abuse prevention training. The facility substantiated the abuse allegation following an internal investigation.
Multiple incidents occurred where residents with cognitive impairments engaged in physical altercations, including hitting, slapping, pushing, and punching, resulting in injuries such as abrasions, hematomas, and fractures. These events were witnessed by staff and documented in clinical records, with care plans in place for behavioral risks but insufficient to prevent abuse. Facility policies defined these actions as abuse, and staff interviews confirmed the incidents did not meet expectations for resident safety.
A resident with dementia and a history of behavioral issues entered another resident's room and allegedly committed physical abuse, resulting in visible bruising. Despite care plans and interventions for supervision, the incident occurred and was reported after the fact, with staff and documentation confirming the abuse. The facility's policies require prompt reporting and investigation, but the events leading up to the incident showed a failure to protect the resident from abuse.
A resident with orthostatic hypotension and hypertension received blood pressure medication outside of physician-ordered parameters, as the MAR showed doses were administered when systolic blood pressure was above the specified threshold. Documentation was inconsistent, with some instances lacking explanatory notes and others marked as administered despite being held, as confirmed by LPN and DON interviews.
Failure to Prevent Resident-to-Resident Abuse Due to Lack of Supervision
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. The incident involved two residents with significant cognitive and behavioral health issues. One resident, who had a history of agitation and impulse control problems, became agitated in the dining room and physically confronted another resident who was exhibiting disruptive behaviors. The aggressor stood up from her wheelchair, placed her hands on the other resident's shoulders and neck, and during the altercation, her arm made contact with the other resident's nose, resulting in a nosebleed. Staff interviews and clinical record reviews revealed that there was no staff present in the dining room at the time of the incident, allowing the altercation to occur without immediate intervention. The incident was witnessed by a CNA through a window, who then called for assistance and separated the residents. The lack of supervision in the dining area was identified as a contributing factor, as staff were occupied with other duties such as medication administration, admissions, and communicating with family members. The facility's policies required prompt reporting and intervention in cases of abuse, but the absence of staff in the dining room allowed the situation to escalate. Both residents involved had complex medical and psychiatric histories, including cognitive impairment, behavioral symptoms, and a tendency toward agitation. The facility's failure to ensure adequate supervision and prevent resident-to-resident abuse resulted in physical harm to one resident. The incident was substantiated by staff interviews, clinical documentation, and policy review, confirming that the facility did not uphold its obligation to protect residents from abuse as outlined in its own policies.
Failure to Prevent Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision to prevent an avoidable accident involving a resident with moderate cognitive impairment and a history of unsafe behaviors, including wandering, exit-seeking, agitation, and poor safety awareness. The resident, who was admitted with diagnoses such as Wernicke's Encephalopathy and unsteadiness on feet, was residing in a locked dementia unit. Despite the presence of door alarms and staff assigned to monitor the area, the resident was able to leave the unit undetected. Staff became aware of the resident's absence only after hearing an alarm and conducting a sweep of the unit, at which point the resident was found missing. Subsequently, the resident was located outside the facility, less than 500 feet from the driveway entrance, attempting to wheel himself away. During the attempt to evade staff, the resident tipped his wheelchair and sustained a scraped knee, necessitating hospital evaluation. Interviews with staff confirmed that the doors were equipped with alarms and that staff were expected to be present in the hallways and dining areas. However, the monitoring in place was insufficient to prevent the resident's elopement and subsequent injury. Facility policy required identification and prevention of unsafe wandering, but the measures in place did not prevent this incident.
Failure to Notify Provider of Held Antihypertensive Medication and Omission of Pre-Transfer Vital Signs
Penalty
Summary
A resident with multiple complex medical conditions, including heart failure, hypertension, diabetes mellitus, respiratory failure, and acute pyelonephritis, was admitted to the facility and later discharged to the hospital. The resident had an active order for Amlodipine Besylate 5 mg daily for hypertension, with instructions to monitor vital signs every shift. On two occasions, the resident's blood pressure medication was held due to low blood pressure readings, but there was no documentation that the provider was notified of the held medication as required by facility policy. Additionally, prior to the resident's transfer to the hospital, vital signs were not obtained and documented, which limited the provider's ability to assess the resident's condition before hospitalization. Interviews with nursing staff and the DON confirmed that the facility's process requires obtaining vital signs before administering blood pressure medication and before hospital transfer, and that the provider should be notified when medications are held. However, review of the medical record and interviews revealed that these steps were not followed in this case. Facility policy on medication administration and transfer/discharge requires medications to be administered as prescribed and for appropriate documentation and communication during transfers. The DON confirmed the absence of documentation regarding provider notification for the held medication and acknowledged that vital signs were not obtained prior to the resident's hospital transfer, as required by facility procedures.
Failure to Timely Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to develop and/or implement policies and procedures to ensure the timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of physical abuse involving a resident. Upon admission, the resident presented with a bruise and reported anxiety related to a neighbor who consumed alcohol. Documentation indicated that the resident attributed the bruise to this neighbor and expressed concerns about safety. Staff interviews and clinical notes confirmed that the allegation of abuse was reported internally, and the executive director was notified. However, there was no evidence that law enforcement was notified of the allegation, as required by facility policy, despite the policy mandating immediate reporting to law enforcement and other authorities. The investigation revealed that the facility reported the allegation to Adult Protective Services (APS) and the Ombudsman several days after the initial report, and the Department of Health Services (DHS) was notified via an online portal. However, review of facility documentation and the DHS complaint portal showed no evidence that the incident was reported to DHS on the date of the alleged incident. Staff interviews indicated confusion and uncertainty regarding whether law enforcement had been contacted, with some staff believing it had been done and others unable to confirm. The executive director ultimately decided not to contact law enforcement, reasoning that the incident occurred outside the facility and emergency services had already been involved. Throughout the period when the allegation was considered valid, the facility operated under the assumption that abuse had occurred, yet failed to follow its own policy requiring immediate notification of law enforcement. The care plan for the resident was not updated to reflect the risk or interventions related to the abuse allegation until several days after admission. The facility's policies clearly required immediate reporting to law enforcement and other authorities, but these procedures were not followed in this case, resulting in a deficiency related to the timely and appropriate reporting of suspected abuse.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
A deficiency occurred when the facility failed to report an injury of unknown origin for a resident to the state agency as required. The resident, who had diagnoses including dementia, borderline personality disorder, and was on anticoagulant therapy, was found with multiple injuries including an abrasion to the lip, redness to the left sclera, and a lump on the back of the head. Documentation showed that the injuries were unwitnessed, and the resident was unable to explain how they occurred due to severe cognitive impairment. The facility's internal records, including care plans and incident reports, documented the injuries and the notifications made to the family, ADON, and physician, but there was no evidence that the incident was reported to the state agency as required by facility policy and regulation. Staff interviews confirmed that the expectation was for injuries of unknown origin to be reported immediately to nursing leadership and, if necessary, to outside agencies. The CNA, LPN, ADON, Social Services Manager, Executive Director, and DON all described the importance of reporting such injuries, especially when the resident cannot communicate what happened. Despite these expectations and the facility's own policies, the incident involving the resident's injuries was not reported to the state agency. The DON stated that the incident did not meet the definition of injury of unknown origin according to their policy, citing documentation that the resident was known to rest her head on the headboard and bite her lip, although this documentation was dated after the incident. A review of the facility's policies confirmed that injuries of unknown source, especially when unwitnessed and unexplained by the resident, are to be reported to the state agency. The facility's incident report log and self-report records did not show any report made for this incident. The failure to report the injury of unknown origin was identified through closed record review, staff interviews, and policy review, establishing that the facility did not follow its own procedures or regulatory requirements in this case.
Failure to Provide Required Documentation During Resident Transfer
Penalty
Summary
The facility failed to provide the required documentation to the receiving facility during the transfer of a resident with multiple diagnoses, including dementia, borderline personality disorder, and a history of falls. The resident, who was on anticoagulant therapy and had documented cognitive impairment and behavioral symptoms, was transferred to the hospital after a family member noticed a bruise and called 911. Upon review, it was found that only a face sheet was provided to the paramedics, and the SNF/NF to Hospital Transfer Form lacked essential information such as relevant diagnoses, vital signs, and pain level. The document checklist on the transfer form was left blank, indicating that no additional documents accompanied the resident during the transfer. Interviews with facility staff revealed a lack of awareness regarding the required documentation for hospital transfers. The Executive Director was unfamiliar with the necessary documents, and the DON stated that only basic information was typically provided. Although a report was called into the hospital, there was no documentation of the specific information relayed. The facility's policy required that a face sheet, advance directives, current physician's orders, and pertinent labs or x-rays be attached during emergency transfers, but this was not followed in the resident's case.
Resident Forced to Shower Against Will by Staff
Penalty
Summary
A deficiency occurred when staff members failed to protect a resident from abuse. The resident, who had a history of dementia, bipolar disorder, major depressive disorder, and anxiety disorder, was care planned for behavioral issues and a tendency to refuse assistance with transfers and showers. On the day of the incident, the resident refused multiple offers for a shower from a CNA, who then notified the assigned RN. The RN instructed the CNA not to ask for consent but to proceed with the shower regardless of the resident's wishes. Subsequently, the RN and another CNA physically removed the resident from bed and forced her into the shower, despite her vocal objections and resistance. The resident expressed distress during the incident, stating she was cold and did not want her hair wet, and was described as angry afterward. Interviews and documentation confirmed that the resident was pulled out of bed by her arms while she was yelling to stop. A bruise on the resident's arm was investigated but determined to have been present prior to the incident. Staff interviews revealed that it was not standard practice for nurses to perform showers and that refusals were typically respected, with documentation of the refusal if the resident continued to decline after being approached by both CNA and nurse. Personnel records for the involved staff showed prior disciplinary actions for discourtesy, insubordination, and failure to follow procedures. Both staff members involved in the incident had completed abuse prevention training earlier in the year. The facility's investigation substantiated the abuse allegation, confirming that the staff members forced the resident to shower against her will, in violation of facility policy and resident rights.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of multiple residents to be free from abuse by other residents, as evidenced by several documented incidents of resident-to-resident altercations resulting in physical harm and psychosocial distress. In one case, a resident with moderate cognitive impairment and a history of dementia was struck in the face with a door by another resident, resulting in an abrasion. The incident was witnessed by a staff member, who observed a verbal argument escalating to physical aggression. The perpetrator, who also had dementia and behavioral disturbances, was placed on increased supervision following the event. Another incident involved a resident with severe cognitive impairment who sustained a hematoma around the left eye after being slapped multiple times by another resident during an altercation in the dayroom. The aggressor, also severely cognitively impaired, had a care plan indicating a risk for verbal aggression. The altercation occurred while an LPN was present in the room but had their back turned at the time. Documentation indicated that the victim exhibited non-verbal signs of pain and distress following the incident. Additional altercations included a resident being pushed to the ground by another, resulting in a fracture, and a separate event where a resident was punched in the stomach after taking another resident's food. There was also an incident where two residents began arguing and physically hitting each other at the dinner table, requiring staff intervention. In each case, the facility's own policies defined such actions as abuse, and interviews with staff confirmed that these events met the definition of abuse and did not meet facility expectations. The report details that care plans for the involved residents included interventions for behavioral risks, but these measures were insufficient to prevent the abusive incidents.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with dementia, COPD, and hypertension, who was cognitively intact according to a recent assessment, reported being physically abused by another resident with severe cognitive impairment and a history of behavioral issues. The incident involved the alleged perpetrator entering the victim's room, hitting her, and causing visible bruising to her arm and face. Documentation and staff interviews confirmed that the victim reported the abuse to staff, and a skin assessment revealed multiple bruises consistent with her account. The alleged perpetrator had a documented history of wandering, impulsive behavior, and physical aggression, as noted in his behavioral treatment plan. The facility's records show that the two residents had been sharing the same unit for an extended period, and the care plans for both included interventions for supervision and maintaining a safe environment. Despite these interventions, the resident with a history of behavioral symptoms was able to enter the other resident's room and allegedly commit physical abuse. Staff interviews indicated that the incident was reported after the fact, and the victim had to leave her room to alert staff. The facility's investigation included interviews, notification of authorities, and review of video footage, although the footage was no longer available at the time of the investigation. The deficiency was further substantiated by the facility's own policies, which require prompt reporting and thorough investigation of abuse allegations. Staff acknowledged the importance of immediate reporting and recognized the incident as abuse. However, the events leading up to the incident, including the lack of effective supervision and the ability of the perpetrator to access the victim's room, directly contributed to the failure to protect the resident from abuse as required by federal and state regulations.
Failure to Administer Blood Pressure Medication per Physician Parameters
Penalty
Summary
The facility failed to ensure that blood pressure medication was administered according to physician-ordered parameters for one resident. The resident had multiple diagnoses, including orthostatic hypotension and hypertension, and was prescribed Midodrine with instructions to hold the medication if systolic blood pressure exceeded 140. Review of the Medication Administration Record (MAR) showed that the medication was marked as administered on several occasions when the resident's systolic blood pressure was above the specified threshold. On some dates, there were no corresponding medication administration notes to explain the deviation, and on other dates, progress notes indicated the medication was held, but the MAR still reflected it as administered. Interviews with nursing staff and the Director of Nursing confirmed that the medication should not have been given when the systolic blood pressure was above 140, and that the MAR documentation did not always accurately reflect whether the medication was administered or held. The facility's policy required medications to be administered in accordance with prescriber orders and for staff to document administration in the electronic MAR after each dose. The failure to follow these procedures resulted in the administration of medication outside of prescribed parameters and inconsistent documentation.
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