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Arizona Nursing Homes Worst Offenders

Arizona Nursing Homes Worst Offenders

The safety of your loved ones is paramount, especially when they are in the hands of a nursing facility. You want staff and fellow residents to be kind, courteous, and caring. But unfortunately, that isn’t always the case. Staff can be abusive or neglectful; other residents can be violent. It’s the management’s responsibility to prevent all types of abuse, and, failing that, to immediately investigate and report the abuse.

Alas, for this roundup of worst offenders, abuse seems to be rampant. Arizona is home to many retirees and older people; it also appears to be a hotbed for nursing home abuse. While not all of the nursing facilities on this list have been cited for abuse, a shockingly large amount have. We’ve compiled this list so you can know what to look for when searching out nursing homes for you or your loved ones -- and to know what to look for in case you already have a relative in a nursing facility.

[Trigger Warning: this post contains descriptions of physical and sexual abuse.]

Haven of Saguaro Valley - Tucson

Medicare.gov overall rating: N/A (too many deficiencies)

The first nursing home in our list has had too many deficiencies to get a rating from Medicare.gov. They have been designated as a “Special Focus Facility,” which Medicare.gov says it has a “history of persistent poor quality of care” and is “subjected to more frequent inspections, escalating penalties, and potential termination for Medicare and Medicaid.” For a series of major and minor violations, Haven of Saguaro Valley earned this ignominious designation.

While this lack of rating is based mainly on the volume of lower-level deficiencies, there is one serious situation from 2018 that illustrates just why it couldn’t earn even one star. Government inspectors cited this facility for not properly taking care of a specific resident’s bed sores. These pressure wounds require constant attention and treatment, with hourly resident rotation to prevent them and regular cleaning to prevent infection. Haven had plans in place according to normal standards, but didn’t follow through. In this case, the resident, with several pressure wounds, was only rotated once every two to three hours. Wound care was irregular and poorly documented. The wounds, of course, got worse until inspectors stepped in.

Desert Cove Nursing Center - Chandler

Medicare.gov overall rating: 1 star (much below average)

There have been a few incidents of alleged abuse at Desert Cove Nursing Center. Some of them could be considered minor, like verbal abuse and another instance of what was mistaken as abuse while a resident was being cleaned. However, Desert Cove makes our list because of the way it handled the abuse allegations. In two such instances, the abuse allegations were essentially ignored by management after residents complained. It doesn’t matter if the facility believes there is no validity to abuse claims; they are required to perform a full investigation and report it to government inspectors. This allows for a pattern to be determined in case there is serial abuse at a facility. Management here, however, didn’t see a need to address the issue.

Mountain View Manor - Prescott

Medicare.gov overall rating: 1 star (much below average)

Sometimes it’s a nursing facility’s obligation to protect residents not just from disease and injury, but from themselves. In the case of Mountain View Manor, they failed that basic task. In 2016 a resident with drug-seeking behaviors was admitted to their facility. The resident had a PICC line (catheter) inserted into his arm. According to a note written by staff, this resident was suspected of cheeking his prescribed pain medication, then using discarded syringes to inject the opioid into the PICC line. (The physician was not notified of this behavior.)

Despite this warning, the resident was able to repeatedly jam his door lock and smoke cigarettes inside. Staff admonished him and even moved him closer to the nurse’s station, but they didn’t take any other precautions. Soon after, the resident was able to sneak his medication and steal a syringe. He injected himself with the Oxycodone and overdosed. 

The staff was not able to resuscitate him. After he died, nursing staff gathered his belongings and found pilfered syringes -- despite staff claiming they had disposed of all syringes and kept them from the resident. It appears they didn’t try hard enough, costing this resident his life.

Payson Care Center - Payson

Medicare.gov overall rating: 1 star (much below average)

There was a rash of resident-on-resident abuse at Payson Care Center, according to a 2018 government report, which was not properly addressed by management. In two instances, two separate residents attacked two other residents. In a third, a resident sexually assaulted another resident. In all cases, the offenders had severe cognitive impairment. We’ll focus on one resident who, for months, was verbally threatening to harm other residents, staff, and visitors to the facility. The nursing home staff did very little to isolate him from other residents and to monitor him. Sure enough, he eventually did assault another wheelchair-bound resident, grabbing her by her shirt and throwing her to the ground after an argument. The fall caused her to break a vertebra which, thankfully, was not paralyzing. Only then did the staff take more stringent precautions to keep this resident from abusing other residents.

Coronado Healthcare Center - Phoenix

Medicare.gov overall rating: 1 star (much below average)

Coronado Healthcare Center had a very bad incident in 2018, where they simply lost a resident. The resident had gone to an off-site physician’s appointment and was due to be returned to the facility by a transportation company. Usually, nursing staff keep a record of these appointments and ensure that residents return back to the facility when the appointments are complete. This time, the nurse on staff got a call from the physician’s office saying the resident was at the wrong office and needed to be picked up. The staff member then called the wrong transportation company. When she realized her mistake, she didn’t immediately call the right company, but instead got sidetracked and forgot to follow up.

She did tell the incoming staff member that the resident was still out, but that staff member didn’t know the resident needed to be picked up. No one realized the resident was missing until 2:30 a.m., at which point they tried to call the physician’s office. Of course, only the answering service picked up. They finally got a call from the hospital at 10 a.m. the next morning saying the resident had been admitted. It appears the physician’s office had left the resident outside to wait for transport that never came. Around 7 p.m. -- three hours after the end of the appointment -- a “concerned citizen” called paramedics because the resident was alone and minimally responsive in her wheelchair. She later died at the hospital of dehydration and kidney failure.

Life Care Center of Paradise Valley  - Phoenix

Medicare.gov overall rating: 1 star (much below average)

Life Care Center of Paradise Valley is the site of a disturbing case of neglect back in 2018. A resident with a medical condition that affected his breathing was found with an altered mental state by a staff member. He was lethargic and not very responsive, so the staff member went to a nurse and asked her to examine the resident right away. The nurse simply shrugged and said no, that he was probably just sleepy. The staff member did the right thing and ran to get a nurse from another floor. That nurse found the resident barely conscious and was “full code” (heart and/or respiration had stopped). The resident was taken to the hospital and treated there -- we don’t know what his status is. However, we do know that the management didn’t investigate the neglect and claims they weren’t aware of it until government inspectors told them. The negligent nurse did resign, but only after the incident was brought up by inspectors.

Desert Highlands Care Center - Kingman

Medicare.gov overall rating: 1 star (much below average)

A tale of an unbalanced wheelchair at the Desert Highlands Care Center led to a fall for a resident. The resident had fallen before and fractured an ankle and femur, leaving him wheelchair-bound until he recovered. One day, the resident was being transported to an off-site doctor’s appointment by a transportation van. The driver had successfully gotten the resident there, but in the parking lot, he unclipped the wheelchair restraints and lowered the ramp to the van. The resident was reclined because of his injuries, which caused the wheelchair to be unbalanced. It tipped over backwards, dumping the resident onto the driver and the ramp. The resident hit his head on the ramp rail and had to be taken to the hospital to be evaluated. Had the driver and nursing facility been more careful, this poor resident could have been saved a nasty bump on the head.

La Estancia Nursing and Rehabilitation Center - Phoenix

Medicare.gov overall rating: 1 star (much below average)

This is a grim tale. At La Estancia, a resident with a history of inappropriate behavior was able to sexually abuse another resident. The male resident -- who was of sound mind -- was caught with his hands in the pants of a female resident with severe dementia. Fortunately, a staff member removed him immediately, and the police arrested the resident. That’s too little, too late, unfortunately. 

Staff members told investigators that the offender had often made inappropriate comments of a sexual nature repeatedly towards staff members. The resident psychiatrist interviewed the offender before the abuse and concluded that despite the behaviors reported by staff, “he did not have any concerns that the resident posed a danger to other residents, or that he had posed a risk for sexual or unwanted behaviors to others.” How wrong he was. Had they recognized the signs, the abuse of a very vulnerable resident could have been avoided.

Oasis Pavilion Nursing & Rehabilitation Center - Casa Grande

Medicare.gov overall rating: 1 star (much below average)

In the summer of 2019, a resident of Oasis Pavilion was the victim of neglect, according to a government report. This resident had no cognitive impairment but did have a diagnosis for diabetes, which was being treated with medication and blood testing. On the day of the incident, the resident had a lower blood sugar and was given food to raise it. Then shortly after lunch, the resident took himself outside. 

There was no official policy to check on residents, but staff said it was “expected” that they should go outside every 15 minutes and check on any residents who may be out enjoying the weather. 

Unfortunately for this resident, nobody checked on him for at least 45 minutes -- in 110-degree heat. It wasn’t until the resident’s visiting family member found him outside that anyone on staff knew something was wrong. The resident had “coded”, meaning he needed emergency intervention to save his life. The team called 911, and he was taken to the hospital.

The report does not mention whether the resident lived or died. But it does state that staff was negligent in allowing him to be alone outside for so long.

Arizona Nursing Home Abuse Lawyers

No matter their age or mental ability, nursing home residents are human beings with all the rights that come with that. Bed sores, abuse, falls, medication mishaps -- all of these things are easily prevented with good policies, proper training, and staff who care about following the rules. 

Yet as we can see here, for many nursing facilities, these basic requirements are hard to follow, resulting in severe injuries and even death. To learn more about what you can do about nursing home abuse and neglect, contact us. Consultations are always free, without obligation and confidential. 

Please contact online, by email [hidden email] or call us at 833.201.1555 to set up a time to talk. We or someone in our network will respond immediately. 


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