Winslow Campus of Care: Abuse Protection Failure - AZ

Resident 71 scored a 5 on her mental status assessment, indicating severe cognitive impairment. Her care plan, updated the day after the incident, noted she "may strike out at men that are in her area and that she is fearful of men she doesn't know."

Resident 84 also had severe cognitive impairment with a mental status score of 6. He was admitted with diagnoses including altered mental status, reduced mobility, depression, alcohol abuse, chronic pain, and difficulty swallowing.

The altercation occurred at 4:17 p.m. on September 23, 2025, in the facility's television room. Video surveillance captured the entire incident.

Resident 84 self-propelled his wheelchair next to resident 71, who was already sitting in the television area. The two residents exchanged words for several seconds before resident 71 began making slapping motions toward resident 84.

Resident 84 then began slapping resident 71 and made physical contact.

Registered Nurse 62 was working at the medication cart nearby during the incident. She witnessed the altercation and separated the two residents.

In an interview conducted a week later, the nurse said she observed both residents "hitting and slapping towards each other." She stated she was "unsure if either resident made contact with the other."

The video surveillance told a different story.

When inspectors reviewed the footage on September 30, the timestamp confirmed the incident occurred exactly when the nurse reported it. But the video clearly showed resident 84 making physical contact while slapping resident 71.

Both residents were assessed for injuries immediately after the incident. Neither had physical injuries from the altercation.

The facility's Director of Nursing 108 was interviewed about the incident on September 30. She stated the incident "would be considered abuse and did not meet her expectations for the facility and could result in psychosocial and physical harm."

The facility's own abuse prevention policy, revised in April 2025, defines abuse as "willful infliction of injury, intimidation or punishment, irrespective of any mental or physical condition." The policy states it is facility policy "to take appropriate steps to prevent the occurrence of abuse."

Resident 71's care plan was updated on September 24, the day after the incident. The updated plan documented her tendency to strike out at unfamiliar men and her fear of men she doesn't know.

No behavioral indicators had been noted in either resident's most recent assessment. Resident 71's assessment showed no documented behaviors despite her severe cognitive impairment. Resident 84's quarterly assessment, also dated before the incident, similarly noted no behavioral concerns.

The registered nurse who witnessed the incident said she separated both residents immediately. She conducted skin assessments on both residents and found no physical injuries.

The incident occurred in the facility's common television room, where both residents were sitting in their wheelchairs. The nurse was positioned at a medication cart nearby, close enough to witness the altercation as it developed.

Federal inspectors reviewed nursing progress notes documenting the incident. One note, dated September 23 at 6:14 p.m., stated that at 4:17 p.m. the registered nurse "witnessed an altercation between resident #71 and another resident." The note confirmed resident 71 "had no physical injuries from the incident."

A second progress note, also dated September 23 at 6:10 p.m., documented that resident 84 "was witnessed by staff #62 hitting another resident before both residents were separated by staff."

The video surveillance system captured the incident with precise timing. When inspectors accessed the footage, they could verify the exact sequence of events and confirm which resident made physical contact.

During the interview, the registered nurse described working at the medication cart when she observed the two residents in their wheelchairs. She said both residents were "hitting and slapping towards each other" before she intervened to separate them.

Her uncertainty about whether contact occurred contrasted with what the video clearly showed. The surveillance footage documented resident 84 making physical contact while slapping resident 71.

The facility's abuse prevention policy requires staff to take appropriate steps to prevent abuse. The policy makes no distinction based on the mental or physical condition of those involved in incidents.

Both residents' severe cognitive impairment was well-documented. Resident 71 scored 5 out of 30 on her brief interview for mental status, while resident 84 scored 6. These scores indicate both residents had significant cognitive limitations that would affect their understanding and decision-making abilities.

The incident raised questions about supervision of residents with documented cognitive impairment and behavioral tendencies. Resident 71's care plan, updated after the incident, specifically identified her tendency to strike out at unfamiliar men.

The director of nursing's assessment that the incident constituted abuse aligned with the facility's written policy. Her statement that it "did not meet her expectations for the facility" acknowledged the seriousness of what occurred.

The timing of the care plan update suggests staff recognized resident 71's behavioral patterns after reviewing the incident. The plan documented both her tendency to strike out and her fear of unfamiliar men.

Federal inspectors found the incident represented a failure to prevent abuse between residents with severe cognitive impairment, despite a registered nurse working nearby who could observe the television room where both residents spent time.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Winslow Campus of Care from 2025-11-19 including all violations, facility responses, and corrective action plans.

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