Hawthorn Court at Ahwatukee

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (A.R.S.) § 46-454(A). 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 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...All of the above reports shall be made immediately by telephone or online." 2. Arizona Administrative Code (A.A.C.) R9-10-101(111) stated “Immediate” means without delay. 3. A review of facility documentation revealed that an incident investigation dated December 17, 2025, at 4:50 PM, documented a resident-to-resident altercation involving physical aggression between R1 and R2. The documentation also reported that E1 was notified on December 17, 2025, at 5:05 PM. However, a review of the documentation revealed that E1 reported the alleged abuse incident to the adult protective services (APS) central intake unit on December 18, 2025, at 4:09 PM. 4. In an interview, E1 acknowledged that APS was not notified immediately. 5. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided. This is a repeat deficiency from the inspection conducted on August 6, 2025.

Based on documentation review and interview, the manager failed to immediately report suspected abuse according to A.R.S. § 46-454. Findings include: 1. A.R.S. § 46-454(A) stated "...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 ... All of the above reports shall be made immediately by telephone or online." 2. A.R.S. § 46-454(B) stated "If an individual prescribed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law..." 3. R9-10-101.110 stated "Immediate" means without delay. 4. A review of R1’s medical record revealed a document titled “Investigation” dated August 4, 2025, which reflected a resident-to-resident physical altercation. The document reported “appropriate state and law enforcement agencies were notified”. 5. A review of the facility’s documentation revealed a document titled “ADHS complaint-Health Care Facility Complaint” dated August 4, 2025, which reflected that no other agency was notified. 6. In an interview, E1 reported that the Department was the only agency notified of the resident-to-resident altercation. E1 acknowledged that a peace officer or the adult protective services central intake unit was not contacted via telephone or email.

Based on observation and interview, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During the environmental inspection, the Compliance Officer observed the following: -The common area was torn and fraying in multiple areas, causing a tripping hazard. -The carpet was also fraying and separating from the transition strip from the wood flooring and carpeted area, posing a tripping hazard. -In the activity area, in the walkway, two large exposed holes in the carpet posed a tripping hazard. 2. In an interview, E1 reported that there was usually furniture placed to cover the holes in the carpet. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.