Brookdale Oro Valley

Based on documentation review and interview, after having a reasonable basis to believe abuse, neglect, or exploitation of a resident had occurred, the manager failed to immediately report the incident according to A.R.S. § 46-454. The deficient practice posed a potential safety risk for residents and a potential rights violation due to a delay in reporting alleged abuse, neglect, or exploitation. Findings include: 1. A review of facility documentation revealed an incident report, dated December 24, 2025, at 7:50 AM, which documented an allegation of physical abuse involving R5 and R7. The report stated, "Resident was resting [R5's] head on the table in the dining room when another resident came up behind [R5] and hit [R5] in the right upper arm/shoulder area. No injury noted. ED notified at 0800 12/24/2025." Under a section titled "Notification Information," the following notifications were documented: E1 was notified on 12/24/2025 at 8 AM, R5's responsible party was notified on 12/24/2025 at 10:10 AM, and R5's physician was notified on 12/24/2025 at 10:30 AM. The incident report included sections for notifications of the police and a state agency; however, these sections had not been filled out. The incident report did not indicate law enforcement or adult protective services were immediately contacted or if an investigation had been initiated. Under follow up information, the report stated, "no follow up entries exist." The report had been approved by E2 on 12/26/2025 at 11:37 AM. Due to the date of the incident and the date of the on-site inspection, the completed incident report was due the day of the on-site inspection. 2. In an exit interview with E1 and E2, the findings were reviewed and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure an assisted living facility had a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of and ensure the health and safety of a resident. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of facility progress notes regarding R2 revealed an entry on September 2, 2025, regarding R2’s out-of-control behavior. The note entry indicated R2 was “agitated,” “aggressive towards care staff,” and “throwing rocks…trying to break the windows and door. The progress notes also indicated “Care staff barricaded in med room and called 911.” Evidence of documentation of any other care staff in the area, or attempts to calm or redirect R2, or ensure the safety of any other residents in the building was unavailable for review. 2. A review of incident reports filed between August 1, 2025, and September 11, 2025, revealed an incident report involving R2, dated September 2, 2025. The report documented an incident of aggressive behavior by R2 towards staff, occurring at approximately 2:30 AM. The incident was described as follows: - “Resident refused to go to bed, was angry and agitated. Exit seeking. [R2] was throwing rocks at staff and pounding/hitting the glass on the medication room door when staff barricaded themselves inside. 911 was called and resident was taken to [the hospital] for evaluation.” Evidence of documentation of any other care staff in the area, or attempts to calm or redirect R2, or ensure the safety of any other residents in the building was unavailable for review. 3. A review of staffing schedules revealed E3 and E6 were the only two care staff on duty during the “10 pm – 6 am” shift on September 2, 2025. 4. In an interview, E1 said E1 did not know where R2 had gotten the rocks R2 threw at care staff during the September 2, 2025 incident. E1 advised E1 did not know if any other residents were near R2 when R2 was displaying aggressive and out-of-control behavior. E1 stated E1 did not know how long R2 was left alone to roam the facility, while E3 and E6 were barricaded in the medication room. E1 added E1 was not aware of any efforts taken by E3 or E6 to calm or redirect R2, nor was E1 aware of any efforts by R3 or R6 to contact E1 or any other employee for assistance, before they locked themselves in the medication room. E1 acknowledged E3 and E6 did not have the qualifications, experience, skills, and knowledge necessary to meet R2's needs and ensure the health and safety of the residents.

Based on documentation review and interview, the manager failed to ensure the facility’s policy and procedure covering how a caregiver will respond to a resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual was implemented. The deficient practice posed a risk as the established and documented policies and procedures were not followed. Findings include: 1. A review of facility policy and procedure, last reviewed October 1, 2024, revealed a policy covering how a caregiver was to respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. The policy indicated caregivers were to take actions such as removing other residents in the area, using calm language, and redirecting the resident. The policy made no mention of employees secluding themselves from the resident displaying the behavior. 2. A review of facility progress notes regarding R2 revealed an entry on September 2, 2025, regarding R2’s out-of-control behavior. The note entry indicated R2 was “agitated,” “aggressive towards care staff,” and “throwing rocks…trying to break the windows and door." The progress notes also indicated “Care staff barricaded in med room and called 911.” Evidence of documentation of any other residents in the area, or attempts to calm or redirect R2, was unavailable for review. 3. A review of incident reports filed between August 1, 2025, and September 11, 2025, revealed an incident report involving R2, dated September 2, 2025. The report documented an incident of aggressive behavior by R2, towards staff, occurring at approximately 2:30 AM. The incident was described as follows: - “Resident refused to go to bed, was angry and agitated. Exit seeking. [R2] was throwing rocks at staff and pounding/hitting the glass on the medication room door when staff barricaded themselves inside. 911 was called and resident was taken to [the hospital] for evaluation.” Evidence of documentation of any other residents in the area, or attempts to calm or redirect R2, was unavailable for review. 4. A review of staffing schedules revealed E3 and E6 were the only two care staff on duty during the “10 pm – 6 am” shift on September 2, 2025. 5. In an interview, E1 said E1 did not know where R2 had gotten the rocks R2 threw at care staff during the September 2, 2025 incident. E1 advised E1 did not know if any other residents were near R2 when R2 was displaying aggressive and out-of-control behavior. E1 stated E1 did not know how long R2 was left alone to roam the facility, while E3 and E6 were barricaded in the medication room. E1 acknowledged E3 and E6 did not implement the facility’s policy on how to respond to a resident’s sudden, intense, or out-of-control behavior.

Based on documentation review, record review, and interview, the manager failed to terminate residency in a manner compliant with R9-10-807(G)(1) for a resident whose behavior posed an immediate threat to the health and safety of other individuals in the assisted living facility. The deficient practice posed a health and safety risk. Findings include: 1. A review of incident reports filed between August 1, 2025, and September 11, 2025, revealed an incident report involving R2, dated September 2, 2025. The report documented an incident of aggressive behavior by R2 towards staff, occurring at approximately 2:30 AM. The incident was described as follows: - “Resident refused to go to bed, was angry and agitated. Exit seeking. [R2] was throwing rocks at staff and pounding/hitting the glass on the medication room door when staff barricaded themselves inside. 911 was called and resident was taken to [the hospital] for evaluation.” The report included a section titled “Follow-Up Information:” which stated, “No Follow Up entries exist.” 2. A review of incident reports filed after September 2, 2025, revealed an incident report involving R2, dated September 10, 2025. The report reflected the incident involved an act of aggression by R2, against R3, which occurred at approximately 12:15 AM. The report indicated R3, who is non-verbal, was sitting alone in the dining room when R2 approached R3 and began to speak to R3. When R3 did not respond, R2 “struck [R3] in the face and then again on the top of [R3’s] head.” According to the report, [R3] was “bleeding profusely from [R3’s] head.” According to the report, R2 struck R3 in the head with “a tape dispenser wrapped in a t-shirt.” A review of facility progress notes regarding R2 revealed an entry on September 2, 2025, regarding R2’s out-of-control behavior. The note entry indicated R2 was “agitated,” “aggressive towards care staff,” and “throwing rocks…trying to break the windows and door. The progress notes also indicated “Care staff barricaded in med room and called 911.” 3. A review of progress notes for R2 revealed an entry on September 2, 2025, which read “Resident refused to go to bed and also refused to take [R2’s] medication. Resident was very agitated and aggressive towards care staff. Resident threw rocks at staff and was trying to break the windows and door. Resident was exit seeking. Care staff barricaded in med room and called 911. Resident was taken out to [the hospital].” Entries on September 10 and September 11 read as follows: -September 10, 2025: “Resident attacked another resident [R3] unprovoked. Resident hit the resident with an item [R2] had in [R2’s] hands twice claiming that [R3] was trying to kill him.” -September 11, 2025: “[Alternate Facility] has agreed to accept [R2]. They are waiting for paperwork from the family, the transfer to their community should happen on Monday 9-15-25. Resident has responded to the increase in his anxiety medications. From 6 am to 10 pm Brookdale staff is s

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified a resident's primary care provider or emergency contact when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of incident reports filed between August 1, 2025, and September 11, 2025, revealed two reports where medical services were called after a resident suffered an emergency or injury. A review of the incident report dated September 2, 2025, revealed at approximately “2:30 AM,” R2 was transported to the hospital after displaying aggressive behaviors, in which caregivers barricaded themselves in a room and called 911. The report included a section for documenting contact efforts of “Family,” which reflected a time of “3:00 AM.” The report also included a section for contacting R2’s “Physician,” which reflected a time of “10:15 AM.” A review of the incident report dated September 10, 2025, revealed at approximately “12:15 AM,” R3 was a victim of an attack and suffered head injuries requiring emergency medical services. The report included a section for documenting contact “Family,” which reflected a time of “9:30 AM,” and a section for contacting R3’s “Physician,” which reflected a time of “8:45 AM.” 2. In an interview, E1 agreed there was no evidence to indicate emergency contacts and/or primary care providers were immediately notified, for incidents in which R2 or R3 required medical services.

Based on record review and interview the manager failed to ensure a caregiver or assistant caregiver documented services provided in the resident's medical record. Findings include: 1. A review of R2’s medical record revealed a current service plan indicating R2 received directed care services, which included a variety of assisted living services, including “Night Checks, Resident will receive night checks every 2-4 hours or as determined by the resident’s need.” 2. A review of R2’s medical record revealed documentation of activities of daily living, which included “Night Check every 2 hours.” The service was documented as being provided on every shift during June 2025, with the exception of the 10:00 p.m. to 6:00 a.m. shift on June 3, 5, and 30, 2025. 3. In an interview, E1 acknowledged R2’s medical record did not contain evidence of documentation of R2 receiving night checks on each night shift in June 2025.

Based on record review, documentation review, and interview, the manager failed to ensure a resident is treated with dignity, respect, and consideration. Findings include: 1. A review of R1’s medical record revealed a service plan, dated April 23, 2025, for directed care services, which included the service “Bathroom Assistance.” The service plan indicated R1 is “unable to use the bathroom on their own and requires assistance pulling up/down pants, handling toilet paper, wiping, changing protective undergarments and getting onto/off of toilet.” The service plant also indicated R1 “required a bathroom schedule; frequently during the day and as needed at night.” 2. A review of facility documentation revealed an email dated June 28, 2025, from O1 to several facility employees, including E2, documenting O1’s observation of R1 not being toileted for eight hours, between 11:45 a.m. and 7:45 p.m. The email indicated O1 had a conversation with E2 the week prior, inquiring about “how many hours a resident sits in wet briefs before they are changed.” Additionally, the email indicated R1 had “… a pressure ulcer…” on R1’s backside and received ointment on R1’s backside to control rashes. 3. A review of facility documentation revealed an incident report dated July 1, 2025, documenting receipt of O1’s June 28, 2025, email. The report documented “no injury” to R1 after a skin evaluation, but indicated R1’s service plan would be changed to reflect O1’s request to change R1 every 4 hours, if needed. 4. In an interview, E1 agreed R1’s service plan had not been updated to reflect an increase in frequency of toileting assistance for R1. E1 acknowledged R1 had not been treated with consideration when R1 was not checked for toileting needs for eight hours.