Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Plaza Healthcare during CMS and state inspections, most recent first.
G-tube Medication Administration Not Performed per Policy: An LPN and an RN were observed administering crushed medications via G-tube without consistently following facility policy. One LPN did not identify a resident by wrist band, and both the LPN and RN were observed giving meds while residents were lying supine with the HOB not elevated. The RN also did not check tube placement or residual before flushing, and syringes were left in bedside containers or returned to bags without rinsing, contrary to the DON’s stated procedure and facility policy.
Expired and unlabeled medications were found in medication carts and medication rooms, along with loose pills that were not identifiable. An RN Unit Manager and an LPN observed loose tablets in carts, and multiple expired items were identified, including Sodium Chloride syringes, Chlorhex Gluconate solution, Milk of Magnesia, Pramoxine Hydrochloride, and Biofreeze Gel. An open bottle of Fish Oil was also found in the refrigerator without an open date. The DON stated that expired medications should be removed from stock and opened medications should be labeled with an open date.
The facility failed to maintain complete and accurate medical records for four residents, leading to deficiencies in documentation and investigation of reported incidents. A resident's report of missing items was not documented, and there was no evidence of an investigation. Another resident's records lacked documentation for an x-ray order and an incident with another resident. Additionally, a resident's report of missing money was not documented, and there was no evidence of an investigation. Staff interviews revealed inconsistencies in documentation practices, with some staff indicating that incidents should be documented in progress notes and care plans, while others believed it was unnecessary.
A resident with multiple medical conditions was found with three medications at her bedside that were not ordered by a physician and without a documented assessment for self-administration. Staff were unaware of the medications, which had been brought in by the resident's family, and facility policy requiring assessment and physician order for self-administration was not followed.
Surveyors found a bag of pork breast in the kitchen refrigerator that was not properly labeled with open or expiration dates, despite being significantly past the dates written on the bag. Dietary staff and the kitchen manager confirmed that food items must be labeled and that unlabeled or expired items should be discarded, but this protocol was not followed.
Two residents with indwelling urinary catheters were observed with their catheter drainage bags lying on or touching the floor, contrary to infection control protocols. Staff interviews confirmed that catheter bags should not be on the floor, and facility policy requires proper placement to prevent contamination.
A resident with moderate cognitive impairment was verbally abused by another resident during a bingo game. The incident involved derogatory language and was witnessed by staff, who failed to intervene or report it immediately. The facility's policy requires protection from all forms of abuse, highlighting a deficiency in adherence to these protocols.
A resident with moderate cognitive impairment was verbally abused by another resident with intact cognition but poor impulse control during a bingo game. Despite witnessing the incident, a staff member failed to intervene or report the abuse, believing it to be a joke. The facility's policy requires immediate reporting of abuse, which was not followed, leading to a deficiency in protecting residents from further abuse.
G-tube Medication Administration Not Performed per Policy
Penalty
Summary
The facility failed to follow professional standards of practice and its own policies during medication administration via gastrointestinal tube for multiple residents. During one observation, an LPN entered a resident’s room with crushed medications mixed in water and a cup of water, but did not identify the resident by wrist band before administration. The resident was observed lying supine with the head of the bed not elevated while the LPN administered the medications through the gastrointestinal tube. After administration, the LPN placed the syringe on the bedside container instead of placing it in the dated bag, and the resident was left lying flat when the LPN exited the room. During a second observation, the same LPN identified another resident by wrist band, but the resident was also observed lying supine with the head of the bed not elevated during gastrointestinal tube medication administration. The LPN removed a syringe from a sealed, dated bag, checked tube placement and residual, flushed the tube with water, administered the crushed medications mixed with water, and then placed the syringe back into a dated bag without rinsing it with water. In interviews after the observations, the LPN stated the head of the bed should be elevated 30-40 degrees during administration and that the syringe should be placed in a dated plastic bag to protect the resident from bacteria or infection. A separate observation with an RN showed medications being crushed together and mixed with water before administration through a gastrointestinal tube. The RN flushed the tube with water, administered the medication mixture, and then flushed again, but was not observed checking tube placement or residual before the initial flush. The RN placed the syringe in a container on the bedside table rather than in a dated bag and did not rinse it after use. The DON stated that tube placement and residual should be checked before administration, medications should be given one at a time, crushed one at a time, the head of the bed should be elevated 30-40 degrees before administration and kept elevated for 30-45 minutes after, and the syringe should be placed in a dated, sealed bag.
Expired and Loose Medications Found in Carts and Medication Rooms
Penalty
Summary
Expired and improperly stored medications were found in multiple medication carts and medication rooms during observations with nursing staff. One medication cart contained eight loose medications at the bottom under resident medication cards, and the RN Unit Manager stated the pills were not identifiable. Another medication cart contained one loose white pill in the bottom of the drawer that was also not identifiable or labeled. The RN Unit Manager stated loose medications in the cart could result in residents not receiving medication as ordered and the medication count being off, and the LPN stated the loose pill was discarded after it was observed. Additional observations identified expired or improperly labeled medications in storage areas. In one medication refrigerator/freezer, four 10 mL syringes of Sodium Chloride were found with an expiration date of January 1, 2026. In another medication room, an open bottle of Fish Oil 1,600 mg was in the refrigerator without an open date. A separate medication room contained Chlorhex Gluconate Solution .12% with an expiration date of December 22, 2025. Another medication cart contained an open bottle of Milk of Magnesia with an expiration date of April 2026, Pramoxine Hydrochloride 1% with an expiration date of January 2024, and Biofreeze Gel with an expiration date of March 2025. The DON stated that expired medications should be removed from stock, that opened medications should be labeled with an open date, and that loose medications in carts could lead to diversion or administration to the wrong resident.
Deficiencies in Documentation and Investigation of Incidents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents, leading to deficiencies in documentation and investigation of reported incidents. For Resident #236, the facility did not document the resident's report of missing personal items and money, nor was there evidence of an investigation or completion of a Make it Right form. Interviews with staff revealed inconsistencies in the documentation process, with some staff stating that reports of missing items should be documented in progress notes and care plans, while others believed it was not necessary as it was not a medical issue. Resident #241's records lacked documentation regarding the reason for an x-ray order and an incident involving another resident. The facility's investigation into the incident was not included in the clinical record, and staff interviews highlighted a lack of consistent documentation practices for incidents and allegations of abuse. Staff members indicated that it was facility policy to document such incidents in progress notes and the clinical record to ensure a history of behaviors and protect residents. For Resident #9, the facility did not provide evidence of documentation regarding an incident with another resident, and the investigation was not included in the clinical record. Similarly, Resident #240's report of missing money was not documented in the clinical record, and there was no evidence of an investigation. Staff interviews revealed that reports of missing items and money should be documented in progress notes, with follow-up on investigations included, but this was not consistently done. The facility's failure to maintain accurate and complete records could result in records that do not accurately reflect the care and services provided to residents.
Failure to Ensure Safe Medication Self-Administration
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication, as evidenced by the presence of three medications on the resident's bedside table without a physician's order or a documented assessment for self-administration. The resident, who had diagnoses including acute kidney failure, hyperlipidemia, and cerebral infarction, was found with Osha Root Rocky Mountain Throat Syrup, Salonpas Lidocaine Plus Pain Relieving Cream, and Fluid Extract Mullein Leaf 2,000mg in her room. There was no evidence in the clinical record of a self-administration order, nor any documentation of an assessment to determine the resident's ability to safely self-administer medication. The care plan did not address medication self-administration, and the medications found were not listed in the physician's orders. Staff interviews confirmed that the medications were brought in by the resident's family and that staff were unaware of their presence until the surveyor's observation. Facility policy requires an interdisciplinary assessment and physician order for self-administration, but no such process was documented for this resident. Staff also stated that medications brought in by families should be removed and that no residents were currently authorized for self-administration. The lack of assessment, documentation, and oversight led to the resident having access to and potentially using medications without proper authorization or monitoring.
Failure to Properly Label and Date Food Items in Kitchen
Penalty
Summary
During a kitchen inspection, surveyors observed a ziplock bag labeled as pork breast in the walk-in refrigerator. The bag had two dates written on it, December 30, 2024, and January 6, 2025, but did not indicate which was the open date or the expiration date. The pork breast was found to be 22 days past the first date and 15 days past the second date at the time of inspection. The Dietary Director was unable to clarify the open or expiration date for the pork breast. Interviews with dietary staff and the kitchen manager confirmed that food items are required to be labeled with both the date opened and the expiration date, and that items not properly labeled should be discarded. The staff acknowledged that the pork breast was from a previous menu and had not been discarded as required. Facility policy also mandates that frozen meat and poultry must be labeled and dated, but this was not followed in this instance.
Failure to Maintain Infection Control Standards for Catheter Bag Placement
Penalty
Summary
The facility failed to maintain infection prevention and control standards regarding the management of urinary catheter bags for two residents. For one resident with hemiplegia and traumatic brain injury, observations revealed that the urinary catheter bag was found lying on the floor, and later placed in a plastic basin that was also on the floor. Staff interviews confirmed that catheter bags should not touch the floor due to infection control concerns, and facility policy supports this standard. For another resident with acute kidney failure, dependence on renal dialysis, sepsis, and a history of urinary tract infection, multiple observations showed the suprapubic catheter bag lying on or touching the floor on several occasions. Staff interviews indicated that catheter care is performed regularly and that catheter bags should be kept off the floor, typically hooked to the bedside rail. Facility policy and referenced nursing guidelines also state that drainage bags should not be placed on the floor to reduce the risk of contamination.
Failure to Prevent Verbal Abuse During Bingo Game
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident during a bingo game. Resident #30, who has moderate cognitive impairment, was verbally abused by Resident #54, who has intact cognition but poor impulse control. During the bingo game, Resident #54 became upset and used derogatory language towards Resident #30, calling her a 'black bitch' after she won a round of bingo. This incident was witnessed by other residents and staff members. Staff #48, a receptionist, was present during the incident but did not intervene or report the verbal abuse, as she thought the residents were joking. Staff #77, the Activities Assistant, was also present and later reported the incident to her supervisor after Resident #30 expressed her upset feelings about the derogatory terms used against her. The Social Services Director, Staff #62, acknowledged that Staff #48 failed to act according to the facility's abuse policy, which requires immediate intervention and reporting of abuse incidents. The facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property clearly states that residents should be free from all forms of abuse, including verbal abuse. The policy defines verbal abuse as the use of disparaging or derogatory language towards residents. The failure of staff to intervene and report the incident immediately represents a deficiency in the facility's adherence to its own policies and procedures, potentially resulting in emotional harm to the residents involved.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure staff intervened and reported an incident of resident-to-resident verbal abuse. Resident #30, who has moderate cognitive impairment, was involved in a verbal altercation with Resident #54, who has intact cognition but poor impulse control. During a bingo game, Resident #54 became upset and used derogatory language towards Resident #30, calling her a 'black bitch' after she won a round of bingo. This incident was witnessed by other residents and staff members, including Staff #48 and Staff #77. Staff #48, who was present during the incident, did not intervene or report the verbal abuse, believing it to be a joke. Despite having received abuse training, Staff #48 failed to recognize the seriousness of the situation and did not inform any supervisors or other staff members about the altercation. Staff #77, who was also present, reported the incident to her supervisor after being informed by Resident #30 about the derogatory language used by Resident #54. The facility's policy on abuse, neglect, and mistreatment requires immediate reporting of any abuse or suspicion of abuse to the Administrator. However, this policy was not followed by Staff #48, leading to a failure in protecting the residents from further abuse. The Social Services Director expressed disappointment in Staff #48's inaction and emphasized the importance of intervening and reporting such incidents immediately, regardless of the department the staff member belongs to.
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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 | 1.9 mi | ★★★★★ | 13 | 0 |
| Osborn Health And Rehabilitation | 1.9 mi | ★★★★★ | 1 | 0 |
| Heritage Court Post Acute Of Scottsdale | 1.9 mi | ★★★★★ | 1 | 0 |
| Rehab At Scottsdale Village Square | 2 mi | — | 20 | 0 |
| Mirabella At Asu | 3.7 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.