Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Court Post Acute Of Scottsdale during CMS and state inspections, most recent first.
A resident with multiple medical conditions, assessed as cognitively intact, reported a serious allegation of sexual abuse to staff. Although internal investigation was initiated, the facility did not report the allegation to the state agency as required by policy. Staff interviews confirmed awareness of the allegation and the expectation for immediate reporting, but documentation and self-reports were not provided to surveyors until specifically requested, and there was no evidence of timely external notification.
A resident with multiple medical conditions was administered Sertraline, a psychotropic medication, without documented consent or evidence that the resident or their representative was informed of the medication's risks and benefits. While consents for other antidepressants were present, facility staff and policy required consent for all psychotropic medications, which was not obtained for Sertraline.
A resident with cognitive impairment and a fungal rash was found with multiple cups of medicated anti-fungal cream left on the bedside table. Staff and the DON confirmed that medicated creams should not be left at the bedside, and facility policy requires nurses to remain with residents until medication is administered.
Two residents with indwelling catheters did not have physician orders for the catheter or for catheter care upon admission, despite care plans indicating the need for such care. The absence of orders was confirmed by nursing staff and the DON, and no catheter care was documented in the treatment records until orders were eventually obtained, contrary to facility policy.
Two residents with physician orders for continuous oxygen therapy did not consistently receive oxygen as prescribed. Observations showed both residents were at times not using a nasal cannula or receiving oxygen, and in one case, oxygen was administered at a higher rate than ordered. Staff and DON interviews confirmed the orders were not followed, despite facility policies requiring accurate implementation of provider orders.
A resident with a hip fracture reported that an LPN applied a pain patch without proper communication, grabbed and twisted her arm, and responded to her request to speak to a supervisor with dismissive and demeaning remarks. Staff interviews revealed a pattern of the LPN speaking to residents in an agitated manner, not responding to call-lights, and making inappropriate comments about pain medication. The DON confirmed protocol was not followed regarding communication and reporting of the incident, and the facility could not provide a resident rights policy.
A resident with a recent hip fracture and intact cognition alleged that an LPN twisted her arm and spoke to her in an aggressive manner during a disagreement about pain patch placement. The facility's investigation did not include interviews with nearby residents or fully document witness accounts, despite policy requirements, and prior complaints about the LPN's conduct were not thoroughly explored.
A resident with severe cognitive impairment was mistakenly administered Seroquel, an antipsychotic, after the ADON entered the wrong medication order during admission reconciliation. The error was not identified during the review and verification process, and the medication was given for several days, resulting in over-sedation. The mistake was discovered when the psych provider and family noticed the resident's altered condition.
A resident with severe cognitive impairment and a known risk for wandering was able to leave the facility unsupervised when staff failed to provide adequate supervision and did not recognize the resident as a high elopement risk. The resident was later found outside by police and returned without injury. Staff interviews and documentation revealed that the required monitoring and interventions were not effectively implemented prior to the incident.
Failure to Report Alleged Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse for one resident who was admitted with multiple diagnoses, including a left femur fracture, anxiety disorder, depression, anemia, and cerebral infarction. The resident was assessed as cognitively intact. On a specific date, nursing notes documented that the resident reported believing she was gang raped by night staff. Despite this serious allegation, there was no evidence that the incident was reported to the state agency as required. During the survey, facility staff interviews revealed that the process for handling abuse allegations included immediate reporting to supervisors and, if necessary, to external authorities. Multiple staff members, including CNAs and the ADON, confirmed awareness of the resident's allegation and described the internal investigation process. However, documentation showed that the facility did not self-report the incident to the state agency within the required timeframe, and the Director of Nursing was unable to produce any self-reports or investigations for the relevant period until prompted by surveyors. Policy review indicated that the facility's procedures required immediate reporting of abuse allegations to the Administrator, State Survey Agency, and other authorities, with specific timelines depending on the severity of the event. Despite these policies, the facility did not follow through with external reporting for the resident's allegation of sexual abuse, and internal documentation was incomplete or missing. Staff interviews further confirmed that the required notifications to state authorities were not made.
Failure to Obtain Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident and/or their representative were informed of the risks and benefits of a prescribed psychotropic medication, specifically Sertraline, prior to its administration. Clinical record review showed that while consents were obtained for other antidepressant medications (Duloxetine and Trazodone), there was no documented consent for Sertraline. The resident, who had multiple diagnoses including type II diabetes, depression, anxiety, left leg amputation, thrombosis, insomnia, and chronic pain, was prescribed Sertraline in addition to other antidepressants. The care plan indicated that education about medication risks and benefits should be provided, but there was no evidence in the clinical record that this occurred for Sertraline. Interviews with facility staff, including an LPN and the DON, confirmed that the facility's process requires obtaining consent and educating residents or their representatives before administering psychotropic medications. Both staff members verified that no consent for Sertraline was present in the resident's chart, and there were no progress notes documenting that the resident or representative had been informed about the medication. Facility policy also requires consent prior to administration of psychoactive medications, but this was not followed in the case of Sertraline for this resident.
Medicated Cream Left at Bedside for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including impaired cognitive function and a fungal rash, was found to have four medicine cups containing a medicated anti-fungal cream left on the nightstand next to their bed. Observations confirmed that the medicated cream remained at the bedside for at least 20 minutes. Staff interviews revealed that medicated creams should not be left at the bedside, and the anti-fungal cream in question contained 2% miconazole nitrate. The Director of Nursing confirmed that medications should not be left at the bedside, that the facility did not have a self-medication administration evaluation, and that residents should not be self-administering their medications. The facility's Medication Administration policy required nurses to remain with the resident until all medication is used, and there was no specific policy for medications administered at the bedside. The presence of the medicated cream at the bedside was not in accordance with facility policy or staff expectations.
Failure to Obtain Physician Orders for Indwelling Catheter and Catheter Care
Penalty
Summary
The facility failed to ensure that two residents with indwelling catheters had physician orders for the catheter and for catheter care upon admission. One resident was admitted with a Foley catheter in place following a hospital stay, and although the care plan noted the presence of the catheter and interventions for care, there were no corresponding physician orders for the catheter or for catheter care documented in the medical record from admission through several days after. The Treatment Administration Record also showed no evidence of scheduled or completed catheter care during this period. The lack of orders was confirmed by both a registered nurse and the Director of Nursing during record review and interviews. Similarly, another resident admitted with an indwelling catheter had care plans indicating the need for catheter care and monitoring for infection, but there were no physician orders for the catheter or for catheter care documented until several days after admission. The Treatment Administration Record did not show evidence of catheter care being performed prior to the late entry of the physician order. Both the registered nurse and the Director of Nursing confirmed the absence of required orders for catheter care during this time frame. Facility policy required daily and as-needed catheter care for residents with indwelling catheters, and that all treatment orders be transcribed into the electronic treatment administration record.
Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents with physician orders for continuous oxygen therapy. Both residents had orders specifying oxygen at 2 liters per minute (LPM) via nasal cannula, with the option to titrate up to 5 LPM to maintain oxygen saturation above 90%. Documentation in the Medication Administration Record (MAR) required staff to record oxygen administration and saturation levels every shift. Despite these orders and documentation requirements, observations revealed that both residents were not consistently receiving oxygen as prescribed. For the first resident, who had diagnoses including COPD and multiple rib fractures, care plans and provider orders indicated the need for continuous oxygen therapy. However, on multiple occasions, the resident was observed without a nasal cannula and not receiving oxygen, even though oxygen saturations were being recorded. On another occasion, the resident was found receiving 5 LPM of oxygen when the order specified 2 LPM unless saturations dropped below 90%. The RN and DON confirmed that the resident should have been on 2 LPM based on current oxygen saturation levels and could not explain the deviation from the order. The second resident, with diagnoses including acute kidney failure and diabetes, also had an order for continuous oxygen therapy. Observations on two separate days found the resident without a nasal cannula and not receiving oxygen. The resident reported only using oxygen at night for sleep apnea, despite the order for continuous use. Both the RN and DON confirmed that the resident should have been receiving oxygen at all times per the provider's order. Facility policies required accurate implementation of provider orders and administration of oxygen therapy by licensed nurses, but these were not followed for either resident.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple staff and resident interviews, documentation, and review of facility procedures. One resident, who was cognitively intact and admitted with a hip fracture and other medical conditions, reported that an LPN applied a pain patch without her request and in a manner that caused discomfort. The resident attempted to indicate the correct location for the patch, at which point the LPN allegedly grabbed and twisted her arm, causing pain. The resident also reported that when she requested to speak to someone in charge, the LPN told her there was no one else available and made demeaning remarks about her behavior. Staff interviews corroborated that the LPN spoke to residents in an agitated and impatient manner, and that there were prior complaints from other residents and staff about the LPN's conduct, including yelling at residents, not responding to call-lights, and making inappropriate comments regarding pain medication. The Director of Nursing confirmed that the LPN applied the pain patch at the incorrect time and did not follow protocol by failing to immediately report the resident's request to speak to a supervisor or the allegation of physical contact. The DON also noted that the LPN did not explain her actions to the resident before touching the surgical bandage, which is required to respect personal space. Additional interviews with a CNA and the Social Services Manager revealed that both the resident and her roommate felt intimidated by the LPN, and that the roommate had also experienced rude and dismissive behavior. The Social Services Manager did not document interviews with the residents, and the facility was unable to provide a resident rights policy, only a list of rights residents must abide by. These actions and omissions contributed to a failure to honor residents' rights to dignity, respect, and self-determination.
Failure to Conduct Thorough Investigation of Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation was completed following an allegation of abuse made by a resident with a recent hip fracture and a history of hypertension and hypothyroidism. The resident, who was cognitively intact, reported that an LPN applied a Lidocaine patch in a manner inconsistent with her expectations and, during the interaction, allegedly grabbed and twisted the resident's arm after a disagreement about the patch's placement. The resident also reported that the LPN responded in an aggressive and demeaning manner when she requested to speak to someone in charge. The incident was reported to the Director of Nursing (DON) by a CNA the following morning. The facility's investigation was incomplete. Although the facility's policy required interviews with all relevant witnesses, the investigation did not include interviews with residents in nearby rooms, despite their presence in the facility. The roommate of the resident involved was not interviewed because she had already been discharged, and the Social Services Manager did not document or fully explore what the roommate heard during the incident. Additionally, interviews with other staff and residents revealed prior complaints about the LPN's behavior, including reports of rudeness, yelling, and failure to provide timely pain medication, but these were not fully investigated or documented as part of the incident review. Facility policy required immediate reporting of all identified events to the Administrator and a comprehensive investigation, including interviews with all potential witnesses and those with relevant information. The investigation conducted did not meet these requirements, as key interviews were omitted and documentation was incomplete, resulting in a failure to thoroughly address the abuse allegation as required by facility policy.
Medication Administration Error Due to Incorrect Order Entry
Penalty
Summary
A resident with vascular dementia and severe cognitive impairment was admitted to the facility with a care plan that included administering medications as ordered and monitoring for side effects and behavioral symptoms. The resident's medication orders, based on the hospital discharge summary, did not include Seroquel, an antipsychotic. However, the Assistant Director of Nursing (ADON) mistakenly entered an order for Seroquel instead of the intended medication, Sertraline, and this order was subsequently verified by the physician and administered to the resident. Seroquel was given to the resident on three consecutive days, despite the absence of a diagnosis for schizophrenia or bipolar disorder, which are the primary indications for this medication. The error was discovered when the psych provider, during a visit, discussed the resident's medication regimen with the caregiver, who reported that the resident was not supposed to be on Seroquel. The family also noticed that the resident appeared over-sedated, which was not the resident's normal baseline, and this was documented in the clinical record. Interviews with the Director of Nursing (DON) and the ADON confirmed that the medication reconciliation process failed to identify the error before administration. The ADON acknowledged that the process involved reviewing hospital orders, matching them with diagnoses, and obtaining physician verification, but the incorrect medication was still entered and administered. The facility's policy required admission orders to be reviewed and transcribed based on discharge instructions, but this process was not effectively followed, resulting in the resident receiving an unnecessary antipsychotic medication.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident with a high risk for wandering. The resident, who had diagnoses of encephalopathy, dementia, and Alzheimer's disease, was assessed as high risk for elopement and had a care plan in place that identified interventions such as 1:1 supervision, documentation of wandering behavior, and structured activities. Despite these interventions, the resident was able to leave the facility unsupervised. On the day of the incident, staff noticed the resident was missing from their room and initiated a search. The resident was found outside the facility by police and returned without injury. Interviews with staff revealed that the resident had been seen wandering near the exit, and a nurse had inadvertently allowed the resident to leave, mistaking them for a family member due to their attire. The facility's elopement policy required monitoring of high-risk residents, but the necessary supervision was not effectively implemented prior to the incident. Documentation and staff interviews confirmed that the resident had a severely impaired cognitive status, with a BIMS score indicating severe impairment and a history of wandering behavior. The failure to recognize the resident as a high elopement risk and to provide the required level of supervision directly led to the resident's unsupervised exit from the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Scottsdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Osborn Health And Rehabilitation | 0 mi | ★★★★★ | 1 | 0 |
| Haven Of Scottsdale | 0.1 mi | ★★★★★ | 13 | 0 |
| Rehab At Scottsdale Village Square | 0.9 mi | — | 20 | 0 |
| Plaza Healthcare | 1.9 mi | ★★★★★ | 4 | 0 |
| Mirabella At Asu | 4.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.