Brookdale Baywood

Based on interview and observation, the manager failed to ensure the health, safety, or welfare of a resident was not placed at risk or harm, for one of five residents sampled. The deficient practice posed a risk to health and safety. Findings include: 1. In an interview, R2 reported that it took staff a long time to respond to call button alerts. R2 reported a fall that resulted in a head injury and bruising that occurred two weeks ago after R2 tried using the call button for assistance. R2 called emergency services for assistance because the facility staff did not respond to the call button alert for over an hour. 2. The Compliance Officer observed a faint bruise on the left side of R2’s head. 3. A review of a facility incident report for R2, completed on January 7, 2026, summarized a fall that involved emergency services being called and in which R2 suffered a head injury with bruising. There were no facility witnesses named in the report. 4. In an interview, E1 reported that the facility was experiencing a slow response time to residents who used their call buttons for assistance due to equipment interference errors. The facility was working to remedy the problem through the purchase of new walkie-talkies and pagers that would not interfere with the call button signals. E1 reported the new system should be operational next month. 5. In an exit interview, the findings were reviewed with E1, and no further information was provided.

Based on documentation review and interview, the manager failed to immediately report suspected abuse according to A.R.S. § 46-454. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "A health professional... 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 vulnerable 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 reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 3. In an interview, E1 reported that E1 was aware of an email sent to the facility by R3's [family] alleging abuse by the facility staff. E1 reported E1 was in the process of conducting an internal investigation regarding the email. E1 reported that E1 had called and emailed R3's caseworker to schedule a care plan conference with the representative and the facility. 4. Documentation review revealed the facility's policy and procedure title, "Abuse, Neglect and Exploitation Policy AZ-1." Section F covered External Reporting / Notification (ARS46-454, ALRULES R9-10-803). Item number four reads, "Report to a Peace Officer or Protective Service worker. If a determination is made that there is reasonable basis to believe an incident constitutes abuse, neglect, or exploitation, the Executive Director or designee should report such information or cause a report to be filed with a peace officer or protective service worker as soon as practicable." 5. The Compliance Officer provided E1 with the Onsite Complaint Survey Documents Request form. Requested documents included: Medical records for R1, R2, R3, R4, R5, and R6 "Incident report and investigation document for allegation of abuse, neglect, exploitation AND/OR accidents, emergencies, or injuries that resulted in the resident needing medical services for any of the above resident." 6. The Compliance Officer did not receive an incident report and investigation documents for allegations of abuse, neglect, or exploitation. 7. Documentation of reporting the alleged abuse to a peace officer or adult protective services central intake unit was not available. 8. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 9. This is a repeat deficiency from the inspection conducted on April 15, 2025.