Rule/Regulation Violated:
J. If a manager has a reasonable basis, according to A.R.S. § 46-454 , to believe abuse, neglect or exploitation has occurred on the premises or while a resident is receiving services from an assisted living facility's manager, caregiver, or assistant caregiver, the manager shall:
1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation;
2. Report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454;
3. Document:
a. The suspected abuse, neglect, or exploitation;
b. Any action taken according to subsection (J)(1); and
c. The report in subsection (J)(2);
4. Maintain the documentation in subsection (J)(3) for at least 12 months after the date of the report in subsection(J)(2);
5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in subsection (J)(2):
a. The dates, times, and description of the suspected abuse, neglect, or exploitation;
b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition;
c. The names of witnesses to the suspected abuse, neglect, or exploitation; and
d. The actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and
6. Maintain a copy of the documented information required in subsection (J)(5) for at least 12 months after the date the investigation was initiated.
Evidence/Findings:
Based on record review, and interview, the administrator failed to report an alleged incident of abuse according to Arizona Revised Statutes (A.R.S.) \'a7 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility.
Findings include:
1. A.R.S. \'a7 46-454(A) states: " A. A health professional, emergency medical technician, home health provider, hospital intern or resident, speech, physical or occupational therapist, long-term care provider, social worker, peace officer, medical examiner, guardian, conservator, fire protection personnel, developmental disabilities provider, employee of the department of economic security or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit. The guardian or conservator of a vulnerable adult shall immediately report or cause reports to be made of such reasonable basis to the superior court and the adult protective services central intake unit. All of the above reports shall be made immediately by telephone or online.."
2. Arizona Administrative Code (A.A.C.) R9-10-101(110) states "Immediate" means "without delay."
3. In record review, R1's medical record (received directed care services) included documentation of an "Incident Form," dated April 12, 2023, "Resident... continuously bothers resident R10 because of [R1's] condition and capabilities... believes [R10] is a small child who needs help... continues to physically bother... such as grabbing ... in different areas... while staff tries to separate the two [R1] gets physically and verbally aggressive towards staff and other residents around [R1]. Today...[R1] had... hands in between [R10]'s legs... I did try to stop it, [R1] got physically and verbally aggressive with me. [R1]'s intentions were unclear while trying to explain why [R1] had ... hands between [R10]'s legs but [R10] was clearly in distress and uncomfortable."
4. In record review, R1's medical record included documentation of an "Incident Form," dated January 13, 2024, at 6:34am, which documented, "At approximately 5:45am, during brief change, resident was very combative, hitting the caregiver, calling ... names and telling ... going to shoot ... between the eyes. As the resident was hitting the caregiver the caregiver touched residents arm ... to stop the hitting... the resident stated "I don't like that Bitch, get ... out of here."... We left. It was not until later, when I passed the meds to [R1] ... [R1] showed me the bruise on ... right arm... didn't complaint of pain at that time... let the caregiver know I have to report the injury and ... charted..."
5. R1's record included a "log entry," dated January 13, 2024, which documented, "At approximately 5:45am, this writer and caregiver was attempting to brief change resident, when [R1] began hitting the caregiver... caregiver defended .. self by grabbing the residents arm to stop the hitting, [R1's] arm was hurt during that process. There is a large bruise on resident's right arm. A log entry dated January 14, 2024, documented, "Visible bruising and swelling on resident's right arm noted, resident also stated, "it hurts", when asked. Offered Tylenol for pain, resident refused. A log note by E4, dated January 15, 2024, documented, "If [R1] becomes aggressive during cares, stop and reapproach."
6. During an interview, E3 reviewed the incident forms with the Compliance Officer. E3 reported the date of the April 12, 2023, incident was incorrect, and an interview with E10 revealed the incident actually occurred two - three months ago. E10 was a witness to the incident and documented the incident on the incident form. E3 reported the facility's policy is that caregiver's are to report incidents of suspected abuse to a manager, and document the notification on the Incident Form.
7. During an interview, the findings were reviewed with E1, E2, E3, and E4 who acknowledged the incidents were not reported, as required, per A.R.S. \'a7 46-454(A), and an investigation, including documentation of immediate action to stop the suspected abuse, and actions taken by the manager to prevent the suspected abuse from occurring in the future.
Summary:
The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00144288, 00143139, 00138218, 00105661, 00105373, 00104349, 00105088, 00105047, and 00104750 conducted on September 17, 2025, and September 18, 2025: