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Phoenix Nursing Home Abuse & Neglect Attorneys - Part 1

Phoenix Nursing Home Ratings Graph

Abuse, neglect and mistreatment occurring in nursing facilities is a challenging problem to face. Unfortunately, many types of elder abuse and neglect exists in various forms that are not always clearly evident. The Phoenix nursing home abuse & neglect attorneys at Nursing Home Law Center LLC are witnessing an ever-increasing amount of cases involving abusive behavior, negligence against nursing home victims who are often the most vulnerable and frail. In many incidences, even the most severe case will go unreported because the victim fears retaliation.

Medicare releases information every month on all nursing homes in Phoenix based on the data gathered through surveys, investigations and inspections. The federal agency that maintains the publicly available information states that nineteen (28%) of the sixty-seven Phoenix nursing homes were found to have serious violations and deficiencies that resulted in substandard care. If your loved one was harmed, injured, mistreated, abused or died unexpectedly from neglect while residing at a nursing home in Phoenix, let our network of attorneys protect your family’s rights. We encourage you to contact the Phoenix nursing home abuse & neglect attorneys at Nursing Home Law Center (800-926-7565) today. Schedule a free case evaluation and let us explain your legal options for obtaining monetary recovery through a lawsuit or compensation claim.

The size, scope and numbers of inhabitants of Maricopa County have risen exponentially in the last few decades. The population of the thriving Phoenix metropolitan area has exploded to over 4 million individuals in recent years, of which more than 160,000 are elderly citizens. Many seniors chose to move to the Grand Canyon State to enter their retirement years in a warmer, healthier and more enjoyable climate. However, this influx of the elderly has placed a heavy burden on nursing facilities that are often challenged to meet the demands in an overcrowded residential environment. The results of a lack of sufficient or not properly trained staff have produced catastrophic results in many nursing homes throughout Arizona.

Persistent shortages of professional medical staff to fill positions in nursing facilities often result in employees needing to work double shifts. Because of this burden, some nursing home administrators have chosen to outsource some or all of their nursing staff by bringing in nurses from outside agencies who are often not familiar with the specific needs of the resident’s living in the facility.

Maricopa County Nursing Home Health Concerns

Placing the blame on every incident involving neglect and abuse occurring in nursing facilities because of overworked, stressed out nursing personnel is unrealistic. This is because many incidences of actual cases of neglect are caused by lack of training or the failure of the administration to enforce existing policies, procedures and protocols designed to eliminate serious issues. Many cases of abuse are the result of poor hiring practices where the administration and nursing staff failed to follow proper measures and perform adequate background checks before filling much-needed positions in the nursing home.

Our Phoenix elder abuse attorneys have long served as legal advocates for Arizona nursing home residents who are victimized by their caregivers, other residents, visitors and friends. Our Maricopa County nursing home lawyers continuously review opened investigations, filed complaints and health concerns at nursing facilities statewide. We publish this publicly available information to assist families in making solid, well-informed decisions before placing their loved one in the hands of professional medical staff members to ensure they receive the highest level of health and hygiene care.

Comparing Phoenix Area Nursing Facilities

The detailed list below outlines many of the nursing facilities throughout the Phoenix area that currently maintain a below average rating comparable to other facilities nationwide. This publicly available information has been gathered from many national databases including In addition, our Phoenix nursing home neglect lawyers have summarized our primary concerns over specific facility failures and posted the results below.

Overall Rating of 67 Nursing Homes

    Rating: 5 out of 5 (24) Much above average
    Rating: 4 out of 5 (13) Above average
    Rating: 3 out of 5 (11) Average
    Rating: 2 out of 5 (13) Below average
    Rating: 1 out of 5 (6) Much below average
August 2018

Grace Healthcare of Phoenix
4202 North 20th Avenue
Phoenix, Arizona 85015
(602) 264-3824

A “For-Profit” 100-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Ensure That Residents Are Free from Accident Hazards and Provide Adequate Supervision to Prevent Avoidable Accidents from Occurring

In a summary statement of deficiencies dated 06/11/2015, a complaint investigation against the facility was opened for its failure to “ensure that adequate supervision and preventative measures were in place for [a resident] to help prevent further falls.” This failure of the facility affected one resident with a Brief Interview for Mental Status (BIMS) score of 11 where scores between eight and 12 “indicate moderate cognitive impairment.”

The state investigator reviewed the resident’s Care Plan revealing that the resident “was at risk for falls related to a new environment.” In addition, a goal was set “for the resident to be free of falls and experience no injuries. Interventions included the following: assist with ambulation, keep wheelchair within reach at all times, referred to physical therapy as needed, keep call light within reach, remind resident to ask for assistance, and to monitor for changes that may warrant increased supervision/assistance and notify the physician.”

The claim investigation was initiated after “the resident found on the floor, because everyone ignores him when he asked for help. Again the intervention was to remind the resident to use his call light when he needed help.” This documentation was noted in the 07/26/2014 Nursing Note.

The 12/04/2014 Nursing Note indicated that the “resident was found on the floor between his bed and his dresser. He said he fell while he was trying to get out of bed.” In addition, the resident “was encouraged to use his call light and asked for help when needed.”

The state investigator noted that “Despite multiple falls, there was no documentation that any increased supervision or ongoing safety measures were consistently implemented to help prevent additional falls.”

The state investigator conducted a 07/11/2015 10:10 AM interview with the facility’s Director of Nursing who revealed “that she started at the facility during the last month […and] she was not sure what the facility did for falls at that time […and] that she knew that all falls were reviewed by the interdisciplinary team but had no documents of this.” In addition, the Director of Nursing stated that “as far she knew, interventions, anti-tipping wheelchair, a substance to prevent slipping used for wheelchairs, safety alarms and increased supervision were not attempted. She also said that there were a few falls when there were no new interventions documented […and] that it appeared that the intervention of re-educating the resident to use the call light was ineffective, but staff used the intervention after multiple falls […and] that since she had been in the building, staff are looking at root causes of falls and beginning appropriate interventions and updating the Care Plans.” However, “after this fall, the Care Plan was updated in relation to the fall, but no new interventions were noted.”

Our Phoenix nursing home neglect attorneys recognize the failing to follow protocols to ensure that residents are free from accident hazards and provide adequate supervision to ensure that avoidable accidents are prevented might be considered negligence or mistreatment. In addition, the deficient practice by the nursing staff fails to follow procedures and protocols adopted by Grace Healthcare of Phoenix including the facility’s policies to reduce the risk of falls and injuries.

Suncrest Healthcare Center
2211 East Southern Avenue
Phoenix, Arizona 85040
(602) 305-7134

A “For-Profit” 115-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide Adequate Medical Services and Follow Protocols to Prevent an Existing Bedsore from Healing or Prevent a New Bedsore from Developing

In a summary statement of deficiencies dated 01/26/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure [a resident] received care services to prevent the development of a pressure ulcer.” This deficient practice at the facility involved one resident with a 07/08/2014 Braden Scale for Predicting Pressure Sore Risk results showing the resident “was at high risk for pressure ulcers.”

The deficient practice was noted after review of the resident’s 12/09/2014 Weekly Pressure Ulcer Record documenting that the resident had “an unstageable wound on the left foot that measured 4.0 centimeter by 2.5 centimeters with no depth, drainage or odor. The wound bed was documented as dry, dark blister.” The record also documented “the use of foam heel boots.”

The 12/12/2015 Wound Physician’s Note documented that the resident had “a stage IV pressure ulcer on the left heel, which measured 5.0 centimeters by 3.0 centimeters by 0.2 centimeters and had a small amount of serosanguinous drainage. The wound that was documented as having 26-50% eschar and 1-25% pink granulation.

A review by the state surveyor noted that the resident’s skin care plans were not revised to reflect the physician’s orders. Additionally, there “were no further Braden Scale Assessments completed between October 2014 and December 2014.

The 01/08/2015 Clinical Report Documentation notes that the “resident was admitted to the hospital… due to an unrelated change of condition and return to the facility [at a later date].”

The state surveyor conducted a 01/22/2015 interview with the facility’s Certified Nursing Assistant who stated “that the resident had foam boots that were to be on at all times.”

Our Phoenix nursing home neglect lawyers recognize the failing to follow protocols and procedures when providing care and treatment to residents with existing bedsores can cause additional harm or life-threatening injuries. The deficient practice of the nursing facility at Suncrest Healthcare Center did not follow the facility’s established policies, including their Pressure Ulcer Policy that reads in part:

“Purpose is to promote good skin integrity and to reduce or relieve pressure, or circulation and promote skin protection. The policy included to complete the pressure risk assessment (Braden) no less than quarterly. In addition, the policy stated that the interdisciplinary team will review the resident status and Care Plan for continuing need and/or any modification to the plan.”

Solterra Subacute Services (SFF)
1501 East Orangewood Avenue
Phoenix, Arizona 85020
(602) 944-1574

A “For-Profit” 133-certified bed Medicaid/Medicare-participating facility

Overall Rating – 1 out of 5 possible stars

1 star rating

Primary Concerns –

Failure to Provide Residents an Environment Free of Conditions of Immediate Jeopardy and Substandard Quality of Care

In a summary statement of deficiencies dated 08/07/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “secure three respiratory crash carts, which contain multiple needles, IV solutions, lancets and various other items.” The deficient practice of not securing the respiratory crash carts resulted in a “Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care.” In addition, the facility “also failed to assess for the safe use of side rails for three residents [at the facility] and failed to ensure that one resident’s room was free of an accident hazards.”

The deficient practice was noted after a Condition of Immediate Jeopardy (IJ) was identified. The Administrator and Director of Nursing were informed of the facility’s failure to secure three respiratory carts in various locations throughout the building. Residents and family members were observed around the carts at various times.”

In addition, state surveyor further observed “that the carts were unsecured and had needles, lancets and IV solutions [… with] no effective system in place to verify the contents of the carts.”

Our Phoenix elder abuse attorneys recognize failing to follow protocols, policies and procedures can place the lives and well-being of residents in grave danger. The deficient practice of not securing respiratory crash carts so that residents, visitors and others do not have unsupervised access to needles, IV solutions, lancets and other items might be considered negligence. In addition, the nursing staff at Solterra Subacute Services failed to follow the facility’s January 2012 policy titled Code Cart that reads in part:

“Respiratory Therapy will check every code cart daily. The daily checks will be recorded by initials of the person performing the checks in the log book kept on each cart.

All code carts are checked every day by the Respiratory Therapists or designee for all areas included on the checklist […and] if any equipment is missing, it will be replaced immediately or the code cart will be taken out of circulation until equipment is replaced.”

The Terraces of Phoenix
7550 North 16th Street
Phoenix, Arizona 85020
(602) 944-4455

A “Not for Profit” 64-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Develop, Implement and Enforce Policies and Protocols to Prevent the Spread of Infection throughout the Facility

In a summary statement of deficiencies dated 05/06/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure the Quality Assurance (QA) committee identified quality concerns regarding infection control and implemented corrective action.”

The deficient practice was noted because even though during the survey process, concerns were identified the regarding the facility’s failure to implement infection control procedures for two residents with symptomatic [medical conditions] who are not on contact precautions. Staff were observed entering and exiting the residence rooms, without donning the appropriate PPE [personal protective equipment].”

The state surveyor observed that “there was no PPE (personal protective equipment) available for staff outside the residence rooms or in the hallway, and the Administrator stated that gowns would need to be ordered. Also, there were no signs outside the residence rooms to alert visitors and residents to check with the nurse before entering.”

Additionally, two residents at risk of spreading infection to others “were also observed in the facility’s dining room on 05/04/2015 and 05/05/2015 without gloves or gowns in place.” The result of these factors led to a Condition of Immediate Jeopardy (IJ).

The state surveyor conducted a 05/06/2015 interview with the facility’s Administrator “who stated that they had not identified any concerns regarding infection control measures related to contact precautions and that these concerns were not in the [Quality Assurance and Performance Improvement (QAPI) System (a systematic, data-driven, comprehensive, proactive approach to performance management and improvement].”

Our Phoenix elder neglect attorneys recognize the failing to develop, implement and enforce policies to prevent the spread of infection throughout the facility has the potential to jeopardize every resident. The deficient practice by the nursing staff and administration violates the terraces of Phoenix’s adopted protocols and procedures including its Quality Assurance and Performance Improvement (QAPI) System that is designed to provide security through various means including:

“[Creating] a self-sustaining approach to improving safety and quality also stated as QA is the process of meeting quality standards and assuring that care reaches an acceptable level.”

The activities of [Quality Assurance and Performance Improvement (QAPI) System] involve members at all levels of the organization to: identify opportunities for improvement, address gaps in systems and processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions.”

Westchester Care Center
6100 South Rural Road
Tempe, Arizona 85283
(480) 831-8660

A “Church-related Not-For-Profit” 64-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Primary Concerns –

Failure to Follow Procedures and Protocols When Destroying Medications That Were Dispensed but Not Administered

In a summary statement of deficiencies dated 10/03/2015, a complaint investigation against the facility was opened for its failure to “ensure one Licensed Practical Nurse followed facility policies and accepted nursing practices for the destruction of medications that were dispensed but not administered.” This deficient practice involved one registry nurse at the facility who was “oriented to facility policies and practices on 02/23/2015.”

The complaint investigation was initiated after a review of personal information involving the Licensed Practical Nurse that revealed “documentation that the LPN had a valid license that was active in good standing with the Board of Nursing” and facility investigative documentation regarding possible drug diversion [which revealed] that on 03/05/2015, during a medication/narcotic reconciliation, a facility nurse found that [the Licensed Practical Nurse] had removed four tablets of [an anti-anxiety medication] from a resident’s medication cart and could not account for the medications.”

Additional investigative documentation revealed that “a signed statement dated 03/06/2015 [by the Licensed Practical Nurse] stated that [the nurse] was in the process of administering medication to two different residents, one resident was to receive [a narcotic pain medication] and another resident was to receive [an antianxiety medication].” However, the nurse stated she did not administer the medications and realize she had taken both doses out of the wrong card and place them back in the cart.”

The state surveyor conducted a 09/03/2015 interview with the Licensed Practical Nurse “who had performed the first mycotic count with [the LPN in question] around 9:30 PM on 03/05/2015.” The second Licensed Practical Nurse stated that the LPN in question “had to leave early as the nurse who would be relieving her had not arrived, so she offered to count the narcotics with [the LPN in question].” During the medication, “it was discovered that a blister pack for one resident was missing four tablets that were not accounted for on the control log.” The assisting Licensed Practical Nurse stated that the LPN in question “appeared nervous, but at the time had no explanation as to where the medications were.” At that time, the staff LPN “went and called the Director of Nursing regarding the missing medications […and] stated that [the LPN in question] left the building and when the on-coming nurse arrived they began another narcotic count [to verify the medications were missing].”

The state investigator interviewed the facility’s Assistant Director of Nursing on 09/03/2015 who stated “there is no facility policy regarding the destruction of medications, that the facility followed the pharmacy policies and procedures.” The state surveyor reviewed the job description for Licensed Practical Nurse is at the facility that documents “that all functions shall be performed in accordance with the established policies and practices of the particular institution which the LPN is performing his/her duties.”

Our Tempe nursing home abuse attorneys recognize that any failure to follow protocols and procedures to track, manage, administer, dispense or destroy medications could cause serious harm or injuries to the residents. The deficient practice of the nursing staff at Westchester Care Center fails to follow the facility’s pharmacy policy for destroying medications. That policy reads in part:

“Wasted medication that require disposal) should be destroyed by two licensed nurses employed by the facility, and the disposal should be documented on the accountability record on the line representing that does. This procedure should apply to the disposal of unused doses (whole tablets, partial tablets, unused portions of single dose ampoules and doses of controlled substances) wasted for any reason.”

Life Care Center of Paradise Valley
4065 East Bell Road
Phoenix, Arizona 85032
(602) 867-0212

A “For-Profit” 210-certified bed Medicaid/Medicare-participating facility

Overall Rating – 2 out of 5 possible stars

2 star rating

Phoenix Nursing Home Abuse & Neglect Attorneys - Part 2

Client Reviews

Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric