Caring House

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated that sometimes they could redirect him, but usually not. She stated that staff were supposed to redirect him by talking to him about different topics like baseball. One day, she said he pushed the door open to Resident R4's room and was yelling and demanding attention. She stated that Activities staff were pretty good about taking him out to BINGO and other things. She said the fact that Resident R3 became jealous of Resident R4 at

the table with staff was not unusual, but it was the first time Resident R3 had punched another resident. On 09/18/25 at 11:37 AM during an interview, LPN 17 stated that Resident R3 had this tendency of being verbally aggressive. In

this last incident, he was saying that the CNA should not be sitting at the same table with the other resident,

she should be sitting with him. Resident R3 wheeled by and hit Resident R4 on the shoulder. The residents were separated and Resident R3 had a 1:1 so he would not hit anyone else after that. LPN 17 stated it was not unusual for Resident R3 to be so possessive of the women staff. Normally, he would just cuss but that day he did what he would normally not do. And normally, when he did get possessive over staff, we would get activities involved. When asked if

he thought staff could have done anything to keep Resident R3 from hitting Resident R4, LPN 17 stated Sure. I think one of them could have gotten up and given Resident R3 attention. The facility policy titled Abuse Prohibition, Reporting and Investigation, revised 4/25, included the facility prohibits the use of verbal, mental, sexual, physical, or physical abuse, corporal punishment, or involuntary seclusion. Each resident has the right to be free from abuse, neglect, or corporal punishment of any type by anyone. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility will provide a safe resident environment and protect residents from abuse.

Procedure(s) included resident to resident abuse: A resident-to-resident altercation should be reviewed as

a potential situation of abuse.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Caring House

510 South Ocotillo Road Sacaton, AZ 85147

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Supervision of Residents, Reviewed/Revised 01/2025, included safety, risks, and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards

in the environment, including adequate supervision. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, then adjusts the interventions accordingly.

Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.The facility policy titled Elopement Prevention and Response, dated 4/2024, included nursing staff must be aware of the resident's location at all times. This includes participating in activities; transport to appointments; authorized passes, etc. If a resident is determined to be missing, unable to be located within 15 minutes or has not been seen by staff within the past 15 minutes, the elopement protocol is activated.During the current onsite survey, the facility provided evidence of corrective actions taken. The actions included:The facility developed and implemented an internal Plan of Correction which included:-Staff education and training on the Custodial Transfer of Responsibility protocol, beginning on [DATE REDACTED] through [DATE REDACTED], which will be monitored for 3 months (12/2025.) This applied to Resident R1 and any other resident who may be affected by the deficient practice. This was a change to their systemic practice.-The facility conducted a Mock Elopement Drill on [DATE REDACTED] with an After Action Review and PowerPoint presentation. This will apply to any other residents who may be affected by the deficient practice.-The Elopement Policy & Procedure was reviewed and updated [DATE REDACTED].-The facility added the 2025 TCH Elopement protocol to their online training system on [DATE REDACTED] so that training for staff is ongoing.-The Health Information Management Coordinator will compile forms weekly and report trends to the QAPI Committee monthly for review for a minimum of 3 months.This facility was able to demonstrate substantial compliance at the time of the survey.This deficient practice represents Past Noncompliance.

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