Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Osborn Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with hypothyroidism, dementia, epilepsy, depression, hypertension, and dysphagia had an order for daily levothyroxine 25 mcg, which was scheduled and initially administered for several days, then not given for multiple subsequent days while the eMAR showed the drug as "pending delivery." During this period, there was no documented notification to the provider that the medication was not being administered, even though physician notes continued to indicate the plan to continue levothyroxine. The drug was not stocked in the automated dispensing system, was not listed on the pharmacy delivery slip, and the pharmacy later reported that the prescription had been set to "profile only" and had never been dispensed until the day of the survey. Facility policies required timely medication receipt, reordering before the last dose, and documentation of unavailable medications and physician notification, but these were not followed, resulting in a failure to obtain and administer the resident’s prescribed levothyroxine.
A resident prescribed Hydrocodone-Acetaminophen for pain management had discrepancies in the documentation of controlled drug administration. While narcotics were pulled from the medication cart and recorded on count sheets, one dose was not documented in the MAR after being administered by an LPN at the family's request. The DON confirmed that this lack of documentation was not in line with facility policy, which requires all administered medications to be accurately recorded.
Two residents in a LTC facility did not receive appropriate assistance with activities of daily living (ADLs). A resident who is legally blind did not receive the required 1:1 assistance during meals, leading to difficulties in eating independently. Another resident, dependent on staff for transfers, was not assisted out of bed despite requests, remaining in bed for several days. The facility failed to adhere to care plans and physician's orders, resulting in unmet needs and potential declines in residents' well-being.
The facility failed to protect two residents from verbal abuse and one resident from physical abuse by a visitor. Two residents exchanged profanities, and a resident with severe cognitive impairment was allegedly abused by her daughter, who threatened and physically hurt her. The facility's response included separating the residents and implementing monitoring, but the incidents were not adequately addressed, leading to a deficiency in ensuring resident safety.
A facility failed to label a Tuberculin PPD Step 2 with an open date in a medication cart, as observed during administration by an RN. The RN acknowledged the oversight, noting the medication's 28-day expiration from opening. CDC guidelines require vials to be labeled with an open date and initials, and discarded if open for more than 30 days or expired.
A resident with a history of hypertension experienced a delay in receiving blood pressure medication despite a high reading. The facility's records showed a gap of nearly six hours between the initial high reading and the next recorded intervention. Staff interviews revealed inconsistencies in communication and documentation, with no clear record of medication administration during this period.
Failure to Obtain and Administer Levothyroxine for a Resident With Hypothyroidism
Penalty
Summary
The deficiency involves the facility’s failure to obtain and provide a prescribed routine medication, levothyroxine 25 mcg, for a resident with hypothyroidism. The resident was admitted with diagnoses including hypothyroidism, Alzheimer’s disease, depression, epilepsy, hypertension, and dysphagia. The comprehensive care plan identified risks related to impaired cognition, ADL self-care deficits, and nutritional problems, with interventions that included administering medications as ordered and monitoring for side effects and effectiveness. An order dated January 7, 2026, directed that levothyroxine 25 mcg be given orally each morning for low thyroid hormone, and the January MAR showed the medication scheduled for 6:00 AM daily. The MAR documented that levothyroxine was administered from January 8 through January 10, 2026, but was not administered from January 11 through January 15, 2026. During this period, eMAR medication administration notes indicated the drug was on “pending delivery,” yet there was no documentation in the progress notes that the provider was notified that the medication had not been administered due to its delivery status. Additional physician progress notes dated January 12 through January 16, 2026, continued to list an assessment and plan of “#Hypothyroid cont levothyroxine,” indicating an expectation that the medication would be continued. A nursing progress note on January 16, 2026, again documented levothyroxine as pending delivery, with no record of provider notification about the ongoing lack of administration. A review of the facility’s automated dispensing system/medication storage list showed that levothyroxine 25 mcg was not stocked there, and a pharmacy packing slip dated January 7, 2026, did not list levothyroxine among the medications delivered for the resident. In interviews, an LPN described the usual process for new admissions, including ordering medications from the pharmacy, using the automated medication storage if an ordered medication is needed immediately, notifying the physician if a medication is unavailable, and documenting such issues and physician notification in the record. The pharmacy technician reported that there was no record of levothyroxine 25 mcg ever being dispensed for this resident prior to the current day and that the original prescription dated January 7, 2026, had been marked “profile only,” meaning it was placed on hold until the facility requested a refill. The DON stated that all admission orders were communicated to the pharmacy through the electronic medical record, that levothyroxine was given for the first three days, and that subsequent notes showed the medication as pending delivery, with an expectation that staff would call the pharmacy or notify the provider if medications did not arrive. Facility policies on administration of drugs, pharmaceutical services, and physician orders required timely receipt of medications, reordering before the last dose, and documentation of unavailable medications and physician notification, which did not occur in this case for the missed levothyroxine doses. The report also includes reference information from the National Institute of Diabetes and Digestive and Kidney Diseases describing hypothyroidism as a condition in which the thyroid gland does not produce enough thyroid hormone, affecting many body functions, and stating that hypothyroidism is treated with levothyroxine, which should be taken as prescribed and not stopped without consulting a doctor. The attending physician/medical director confirmed that the resident had dementia, a history of hypothyroidism, and was on levothyroxine, and stated that the resident should take the medication every day. He reported that he was notified of the pending delivery of levothyroxine and described that in such situations he may allow a hold until the medication arrives, depending on the criticality of the drug. Facility policies reviewed indicated that medications and new orders are to be transmitted electronically to the pharmacy, that refills must be ordered before the last dose is given, and that unavailable medications and physician notification must be documented, underscoring the discrepancy between policy and the lack of documented provider notification and failure to obtain and administer levothyroxine for this resident over multiple days. The surveyors concluded that the facility failed to acquire or obtain levothyroxine, a routine medication, for this resident to treat hypothyroidism, and that this failure could result in the resident’s medical condition not being appropriately treated and place the resident at risk for illnesses. The deficiency was identified under the requirement to provide pharmaceutical services to meet the needs of each resident and to employ or obtain the services of a licensed pharmacist. The sample size for the review was two residents, with this deficiency cited for one resident.
Failure to Maintain Accurate Controlled Drug Records and Documentation
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an accurate account of all controlled drugs was kept for one resident. The resident, who had a history of joint replacement surgery and Alzheimer's disease with dementia, was prescribed Hydrocodone-Acetaminophen for pain management. Review of the medical administration record (MAR) and the controlled drug receipt/record/disposition form revealed discrepancies: two tablets were pulled and administered on one day as documented, but on the following day, an additional tablet was pulled from the cart without corresponding documentation of administration in the MAR. There was no indication that any of the tablets were wasted. Interviews with nursing staff and the Director of Nursing confirmed that the expected process is to document the removal of narcotics from the cart on the narcotic count sheets and to record administration in the MAR. The LPN involved reported administering the medication at the request of the family but failed to document this in the MAR. The Director of Nursing acknowledged the lack of documentation and stated that this omission prevents staff from knowing what was administered to the resident. Facility policy requires accurate preparation, administration, and documentation of all medications once administered.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide appropriate treatment and services for activities of daily living for two residents, leading to deficiencies in care. Resident #320, who is legally blind, required 1:1 assistance during meals as per her care plan and physician's orders. However, observations revealed that staff did not consistently provide the necessary assistance, leaving the resident to eat independently without proper setup or orientation to her meal tray. Despite the resident's expressed need for help in identifying food items, staff failed to comply with the care plan, resulting in the resident struggling to eat and not receiving adequate support. Resident #322, diagnosed with chronic respiratory failure and other conditions, was dependent on staff for transfers and had a care plan goal to maintain her current level of function. Despite her requests to be transferred to a wheelchair, staff repeatedly failed to assist her, citing a lack of approval from physical therapy. The resident remained in bed for several days, expressing frustration and a desire to be mobile, which was not addressed by the facility staff. Observations confirmed that the resident was not assisted out of bed, despite the presence of wheelchairs and the capability of staff to perform the transfer. The facility's policy on activities of daily living, which mandates that residents receive necessary services to maintain their well-being, was not adhered to in these cases. Both residents experienced a lack of compliance with their care plans and physician's orders, leading to unmet needs and potential declines in their physical and psychosocial status. The facility's failure to involve residents in decision-making and provide appropriate assistance contributed to the deficiencies observed.
Failure to Prevent Resident and Visitor Abuse
Penalty
Summary
The facility failed to protect two residents from verbal abuse and one resident from physical abuse by a visitor. Resident #272 and Resident #273 were involved in a verbal altercation where they exchanged profanities. Both residents had intact cognition as indicated by their Brief Interview for Mental Status (BIMS) scores of 15 out of 15. The incident was reported to the Department of Health Services, but the Director of Nursing (DON) could not recall the details of the incident and had to review the investigation notes. The facility's immediate response included separating the residents and implementing 'Change of Condition' monitoring, but the residents refused a room change. Resident #369, who had severe cognitive impairment due to Alzheimer's disease and dementia, was allegedly physically abused by her daughter. The Physical Therapy Assistant (PTA) witnessed the daughter threatening the resident and squeezing her ankle, which the PTA perceived as intentional abuse. The facility conducted an investigation, but the allegation was deemed unsubstantiated. However, supervised visits were implemented during the investigation. The facility's policy requires ensuring the health and safety of residents concerning visitors, but there was no evidence of physician notification or orders for 1:1 visitation following the alleged abuse. The facility's policy on abuse prevention and prohibition outlines the need to protect residents from various forms of abuse, including verbal and physical abuse. Despite this, the facility failed to prevent the incidents involving resident-to-resident verbal abuse and visitor-to-resident physical abuse. The lack of immediate and effective intervention, as well as the failure to recall and address the incidents adequately, contributed to the deficiency in ensuring resident safety and well-being.
Medication Labeling Deficiency in Medication Cart
Penalty
Summary
The facility failed to ensure that a medication in a medication cart was labeled with an open date, as observed during a medication administration by an RN. The RN was administering a Tuberculin PPD Step 2, which was not marked with an open date. During an interview, the RN acknowledged that the Tuberculin PPD should have been dated when opened, noting that the medication has an expiration date of 28 days from opening. A review of the CDC guidelines for the Mantoux tuberculin skin test indicated that vials should be labeled with an open date and the initials of the individual who opened the vial, and any vial open for more than 30 days or past its expiration date should be discarded. This oversight in labeling could lead to improper usage of the medication.
Failure to Administer Timely Blood Pressure Medication
Penalty
Summary
The facility failed to provide services and treatment according to the plan of care and physician orders for a resident with a history of hypertensive heart disease, asthma, atrial fibrillation, and other conditions. The resident was admitted with a care plan that included administering anti-hypertensive medications as ordered. On a specific day, the resident's blood pressure was recorded at a dangerously high level, but there was a significant delay in administering the necessary medication. The resident reported a high blood pressure reading of 167/116, and three hours later, no medication or assistance had been provided. The facility's records showed that the blood pressure was taken at 3:47 pm, but the next recorded intervention was not until 9:41 pm, when the blood pressure had decreased. There was no documentation of any medication being administered during this interval, and the electronic health record did not specify which medication was given or at what time. Interviews with staff revealed inconsistencies in the communication and documentation of the resident's care. Staff members had differing accounts of whether the physician was notified and what actions were taken. The Director of Nursing stated that the facility's policy required reporting and documenting any vital signs outside established thresholds, but this was not adhered to in this case.
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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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Nursing homes near Scottsdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haven Of Scottsdale | 0 mi | ★★★★★ | 13 | 0 |
| Heritage Court Post Acute Of Scottsdale | 0 mi | ★★★★★ | 1 | 0 |
| Rehab At Scottsdale Village Square | 0.8 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.