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 Sante Of North Scottsdale during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of wandering was able to leave the facility unnoticed despite interventions in the care plan, including room relocation and photo identification at nurses' stations. The resident was last seen pacing in the hallway and was later found outside by an EMT. Staff interviews indicated that the resident had expressed a desire to leave and was not observed exiting by front desk staff. The facility's policy required behavioral assessment and monitoring, but these measures did not prevent the elopement.
A resident's wallet containing cash and identification was misappropriated due to the facility's failure to provide a secure storage option. Despite being cognitively intact, the resident experienced confusion about the event. Staff interviews revealed procedural gaps, including the absence of a key for the bedside drawer and lack of communication about securing valuables. Missing keys in several rooms and inconsistent protocols contributed to the deficiency.
A resident reported her wallet missing, but the facility's investigation was incomplete, failing to interview all relevant staff, including CNAs and an agency RN. The AIT did not suspend staff during the investigation, and the facility's abuse prevention policy was not fully adhered to, resulting in a deficiency.
A resident on warfarin therapy for atrial fibrillation experienced dangerously high INR levels due to the facility's failure to adhere to physician orders to hold the medication. Despite elevated INR levels, warfarin was administered, leading to the resident's hospitalization with symptoms of unresponsiveness and altered mental status. Interviews with staff revealed inconsistencies in INR monitoring and communication of results, highlighting a deficiency in care.
The facility failed to administer opioid medications according to physician-ordered parameters for two residents. One resident received hydrocodone-acetaminophen for pain levels of 0 and 5, while another received oxycodone for pain levels ranging from 0 to 5, without proper documentation or physician notification. Staff interviews confirmed these discrepancies, and the facility's policies were not followed, as acknowledged by the administrator.
The facility failed to monitor psychotropic medications for three residents, leading to potential complications. A resident was given Mirtazapine without proper monitoring or a depression diagnosis. Another resident received PRN Ativan despite no documented anxiety or restlessness. A third resident was administered Ativan without evidence of target behaviors, and non-pharmacological interventions were not documented or offered. Staff interviews confirmed these deficiencies, which did not meet the facility's expectations.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to potential infection spread. Observations revealed a lack of signage and PPE availability, with staff not wearing gowns during high-contact interactions. Interviews confirmed the absence of proper PPE use and training, despite care plans requiring EBP for residents with catheters and pressure injuries.
Two residents in an LTC facility did not receive prescribed medications due to unavailability and lack of communication. One resident, with a history of EBV and CMV, missed doses of Maribavir, while another resident did not receive Afrin nasal spray, affecting their blood thinner regimen. Facility staff failed to document and notify providers about these issues, leading to deficiencies in care.
A resident was prescribed Mirtazapine for depression without being informed of its risks and benefits. Despite receiving the medication, there was no documentation of informed consent. Interviews with staff confirmed the lack of documentation, and the resident was unaware of taking the medication. This oversight violated the facility's policy on Resident Rights, which mandates informing residents about their care and treatment.
A resident with communication deficits due to cerebral infarction and dysarthria was not provided with adequate interventions to accommodate their needs. Despite recommendations for communication aids like a whiteboard, these were not consistently available or used. Staff interviews revealed inconsistencies in the assessment and documentation of the resident's communication abilities, posing a risk of miscommunication.
A resident with communication deficits due to cerebral infarction and other conditions was admitted to a facility, but the baseline care plan failed to address these needs within 48 hours. Despite documented issues like moderate dysarthria and cognitive impairment, the care plan lacked necessary interventions. Staff interviews revealed a lack of awareness and implementation of communication strategies, with the Director of Nursing acknowledging the omission and potential risk for harm.
The facility failed to lock treatment carts and remove expired medications. On one floor, a nurse left a cart unlocked, containing medications like hydrocortisone and lidocaine. On another floor, an LPN found expired medications, including Collagenase Santyl and silvasorb gel. Both incidents violated facility policies requiring carts to be locked and expired medications to be removed.
Failure to Prevent Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of wandering and moderate cognitive impairment was not adequately supervised, resulting in the resident eloping from the facility. The resident had diagnoses including nontraumatic acute subdural hemorrhage, type two diabetes mellitus, and vascular dementia, and was identified as being at risk for wandering and elopement in the care plan. Interventions listed in the care plan included identifying the resident's room and bathroom, following protocols for wandering tendencies, keeping the resident's photo at nursing stations and the front entrance, and moving the resident to the second floor. Despite these interventions, the resident was able to leave the facility unnoticed. On the day of the incident, the resident was last seen by staff between 08:30AM and 09:00AM, and was later found missing at 09:20AM, prompting a code pink and a search. The resident was eventually located outside the facility in a nearby soccer field by an EMT, with no injuries noted. Staff interviews revealed that the resident had been observed pacing and lingering in the hallway earlier that morning, and had expressed a desire to leave. The LPN assigned to the resident reported seeing him near the nurses' station shortly before he was discovered missing, and staff at the front desk did not observe the resident leaving the building. The facility's Director of Nursing stated that the facility is not specifically set up for residents with wandering tendencies, but interventions are put in place for those identified as at risk. The DON also noted that the resident had not previously demonstrated exit-seeking behavior during his stay, although he had a history of elopement from a prior facility. The facility's policy requires behavioral assessment and monitoring, and for staffing needs to be evaluated based on resident acuity and care plans, but these measures did not prevent the resident's elopement in this instance.
Failure to Secure Resident's Valuables Leads to Misappropriation
Penalty
Summary
The facility failed to provide a secure environment for a resident's personal belongings, leading to the misappropriation of the resident's wallet containing $53.00, a credit card, two forms of identification, and a medical card. The resident, who was admitted with diagnoses including a periprosthetic fracture, Parkinson's Disease, and dementia, reported the missing wallet shortly after admission. Despite being cognitively intact as per the minimum data set, the resident experienced a possible visual hallucination of someone stealing her belongings, which added to the confusion about the actual events. Interviews with various staff members revealed inconsistencies and gaps in the facility's procedures for securing residents' valuables. The CNA responsible for the resident's admission inventory did not offer a key for the bedside table drawer, nor did she ensure the valuables were secured in the medication cart or facility safe. Additionally, there was no documentation by the LPN or RN on duty regarding the resident's personal belongings, and the CNA did not communicate the presence of valuables to the nursing staff. Further investigation showed that keys for the bedside table drawers were missing in several rooms, and there was a lack of clarity among staff about the protocol for securing valuables. The Guest Services Director and Maintenance Director confirmed that keys often go missing, and there was no consistent process for replacing them promptly. The Acting Administrator acknowledged the failure to secure the resident's belongings and the risk of misappropriation due to the lack of proper procedures and communication among staff.
Incomplete Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation regarding an allegation of misappropriation of a resident's property. Resident #22, who was admitted with diagnoses including a periprosthetic fracture, Parkinson's Disease, and dementia, reported her wallet missing. The inventory of personal effects, signed by a CNA, initially listed the wallet among other items. However, the wallet was not found during a search conducted by the Administrator in Training (AIT) after the resident reported it missing. The investigation was incomplete as it did not include interviews with all relevant staff members, particularly those who worked the noc shift when the wallet was last seen. The AIT interviewed some LPNs but failed to interview CNAs who were directly involved in the resident's care during the relevant time frame. Additionally, the investigation did not include interviews with the RN from the agency who worked the noc shift, as the facility was unable to contact her. The facility's policy on abuse prevention requires thorough investigations and timely reporting of allegations, but this was not adhered to in this case. The AIT did not suspend the staff involved during the investigation, and there was a lack of documentation regarding the resident's statements. The investigation was not comprehensive, as it did not cover all potential staff interactions with the resident's belongings, leading to a deficiency in handling the alleged misappropriation.
Failure in Anticoagulant Therapy Management
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice regarding anticoagulant therapy. The resident, who was admitted with a history of acute cystitis, thrombocytopenia, and other conditions, was on warfarin therapy for atrial fibrillation and required regular monitoring of INR levels to maintain a therapeutic range of 2.5-3.5. Despite physician orders to hold warfarin due to elevated INR levels, the medication was administered on September 7 and 8, 2024, when the resident's INR was significantly above the therapeutic range, reaching levels of 8.0 and 10.0, respectively. The clinical records revealed that the resident's INR was not adequately monitored or managed, leading to dangerously high levels. On September 6, 2024, a physician's note indicated that warfarin should be held for three days due to elevated INR, but this directive was not followed, as evidenced by the administration of warfarin on subsequent days. The resident's condition deteriorated, with symptoms of unresponsiveness, altered mental status, and right-side deficits, leading to hospitalization. Interviews with facility staff, including an LPN, the DON, and the administrator, highlighted inconsistencies in the process of INR monitoring and communication of abnormal results to physicians. The facility's policy required appropriate clinical and laboratory monitoring for anticoagulant therapy, but the failure to adhere to these standards resulted in a significant deficiency in care for the resident.
Opioid Medication Administration Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure that opioid medication orders for two residents were administered according to the physician-ordered parameters. For Resident #4, who was admitted with diagnoses including fibromyalgia and chronic back pain, the physician had ordered hydrocodone-acetaminophen to be administered for a pain level of 6-10. However, the medication was given on two occasions for pain levels of 0 and 5, without documentation of a reason or notification to the physician. Interviews with staff confirmed that the medication was administered outside the ordered parameters. Resident #38, admitted with conditions such as anterior soft tissue impingement and muscle stiffness, had a physician order for oxycodone to be administered for pain levels of 6-10. Despite this, the medication was administered multiple times for pain levels ranging from 0 to 5, again without documentation or physician notification. The resident reported issues with severe itching attributed to the oxycodone and expressed concerns about the timeliness of pain medication administration, indicating that medications were sometimes given late. Interviews with staff, including a CNA and an LPN, highlighted that pain levels and other assessments were supposed to be conducted before administering pain medications. The facility's policies required medications to be administered according to the resident's order and to contact the provider if doses were inappropriate. The administrator acknowledged that the administration of pain medication outside the ordered parameters did not meet facility expectations and policy.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring of psychotropic medications for three residents, leading to potential complications. Resident #42 was prescribed Mirtazapine for depression, but there was no evidence of monitoring for side effects or effectiveness from September 2 to September 8, 2024. Interviews with staff revealed that there was no diagnosis of depression for this resident, and the medication was administered without an end date or proper monitoring, which did not meet the facility's expectations. Resident #1, who was cognitively intact, was prescribed Lorazepam for anxiety, but there was no documentation of anxiety or restlessness from September 1 to September 9, 2024. Despite this, PRN Ativan was administered on several occasions without evidence of the target behavior being present. The Director of Nursing confirmed that unnecessary medications should not be given and that monitoring should be in place to ensure the medication's necessity and effectiveness. Resident #23, with severe cognitive impairment, was prescribed Ativan for anxiety, but there was no documentation of the target behavior of restlessness when the medication was administered. The resident's care plan did not include non-pharmacological interventions, and staff interviews indicated a lack of awareness of such interventions. The Director of Nursing acknowledged that PRN psychotropic medication should only be administered when necessary and that non-pharmacological interventions should be documented and offered prior to medication administration.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards regarding Enhanced Barrier Precautions (EBP) for three residents, leading to potential infection spread. Resident #23, with severe cognitive impairment and a suprapubic catheter, required EBP as per their care plan. However, observations revealed a lack of signage indicating EBP, and staff did not wear gowns during high-contact interactions, such as catheter care and bed-to-wheelchair transfers. Interviews with staff and family confirmed the absence of proper PPE use, and a CNA admitted to not receiving training on transmission-based precautions. Resident #26, also with severe cognitive impairment and a Foley catheter, was observed without EBP signage or PPE availability. Staff entered the room to change soiled linens without wearing gowns, despite the resident's care plan requiring EBP. An LPN initially denied the need for precautions but later acknowledged the oversight. The Director of Nursing confirmed that PPE should be available and signage posted for residents on EBP. Resident #24, with intact cognition and a sacrum pressure injury, was similarly affected by the facility's failure to implement EBP. Observations showed no signage or PPE availability, and a phlebotomist performed a procedure without wearing a gown. Interviews with the wound nurse and DON highlighted the expectation for EBP compliance, yet the facility's policy was not followed. The facility's policy clearly outlined the need for PPE and signage, which was not adhered to in these cases.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications as ordered for two residents, leading to deficiencies in care. Resident #272, who had a history of EBV and CMV, was prescribed Maribavir, an antiviral medication, to be taken twice daily. However, the medication was not administered on multiple occasions due to it being unavailable, either waiting to be brought from the resident's home or pending pharmacy delivery. There was no documentation indicating that the physician was notified of these missed doses, and the resident's family later discovered the medication was never given, as it was returned to them unopened. Resident #277, diagnosed with paroxysmal atrial fibrillation and other conditions, was prescribed Afrin nasal spray, which was not administered over several days due to it being unavailable. The facility failed to notify the provider promptly about the unavailability of the medication, resulting in a delay in obtaining a hold order. The resident experienced nosebleeds, and the facility's failure to administer the nasal spray also led to a hold on the resident's blood thinner medication, Eliquis, which could have increased the risk of blood clots. Interviews with facility staff, including the administrator and DON, revealed a lack of documentation and communication regarding the unavailability of medications and the necessary hold orders. The facility's policies on administering medications and handling shortages were not followed, contributing to the deficiencies in care for these residents.
Failure to Inform Resident of Psychotropic Medication Risks
Penalty
Summary
The facility failed to ensure that a resident was informed of the risks and benefits associated with the use of a psychotropic medication, specifically Mirtazapine. Resident #42, who was admitted with diagnoses including a urinary tract infection, severe sepsis without septic shock, and acute respiratory failure with hypoxia, was prescribed Mirtazapine 15 mg for depression. Despite the administration of the medication from September 2 through September 11, 2024, there was no documentation in the clinical record indicating that the resident was informed about the medication's risks and benefits. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed the absence of documentation regarding informed consent for the use of Mirtazapine. The resident himself stated that he was unaware of taking Mirtazapine or any antidepressant medication. The facility's policy on Resident Rights, which guarantees residents the right to be informed and participate in their care planning and treatment, was not adhered to in this case, as evidenced by the lack of informed consent documentation for Resident #42.
Failure to Address Communication Deficits in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with communication deficits had appropriate interventions to accommodate their needs and abilities. The resident, who was admitted with diagnoses including cerebral infarction, hemiplegia, and dysarthria, had impaired cognition and speech intelligibility issues. Despite these challenges, the resident's care plan did not adequately address the communication barriers, as evidenced by the lack of communication devices like a whiteboard in the resident's room and inconsistent staff awareness of the resident's communication needs. Observations and interviews revealed that the resident had significant difficulty being understood due to slurred speech and hearing impairment. Staff members, including a CNA and a speech therapist, noted the resident's challenges in communication, yet there was no consistent use of recommended communication aids such as a whiteboard. The speech therapist had informed nursing staff about the need for such aids, but this was not reflected in the care plan or consistently implemented in practice. Interviews with facility staff, including the Director of Nursing and the MDS coordinator, highlighted discrepancies in the assessment and documentation of the resident's communication abilities. The MDS assessment inaccurately coded the resident's speech as clear, despite evidence to the contrary. The lack of a comprehensive care plan addressing the resident's communication deficits posed a risk of miscommunication, potentially affecting the resident's ability to express needs and preferences effectively.
Failure to Address Communication Deficit in Baseline Care Plan
Penalty
Summary
The facility failed to address a resident's communication deficit in the baseline care plan within 48 hours of admission. The resident, who was admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, and encephalopathy, had documented communication difficulties such as moderate dysarthria and cognitive impairment. Despite these documented issues, the baseline care plan did not include goals or interventions to address the resident's communication needs until several days after admission. Observations and interviews revealed that the resident had significant communication challenges, including slurred speech and difficulty being understood. The speech therapy evaluation noted the resident's moderate dysarthria and cognitive impairment, recommending strategies to improve communication. However, these recommendations were not incorporated into the baseline care plan promptly, leaving the resident without necessary communication support. Interviews with staff, including a CNA and the speech therapist, highlighted a lack of awareness and implementation of communication strategies for the resident. The CNA was unaware of any specific communication recommendations and noted the resident's difficulty in being understood. The speech therapist confirmed the resident's communication issues and stated that recommendations were verbally communicated to nursing staff, but these were not reflected in the care plan. The Director of Nursing acknowledged the omission and recognized the potential risk for harm due to ineffective communication.
Failure to Secure Treatment Carts and Remove Expired Medications
Penalty
Summary
The facility failed to ensure that treatment carts were locked and supervised, as well as to remove expired medications from the treatment cart. During an observation on the second floor, a nurse left the treatment cart unlocked and unsupervised while entering a resident's room. An LPN confirmed that medication carts should be locked when unsupervised and admitted to not knowing the risks associated with an unlocked treatment cart. Upon inspection, the cart contained various medications, including hydrocortisone, silvasorb gel, diclofenac sodium, triamcinolone, clobetasol, and lidocaine, which were accessible due to the cart being left unlocked. On the first floor, another LPN was observed with a treatment cart containing expired medications, including Collagenase Santyl, silvasorb gel, and a Binax COVID test kit. The LPN acknowledged the risk of residents accessing medications from an unlocked cart and removed the expired items, stating that expired medications are typically taken to the DON's office. The facility's policy mandates that medication carts be locked when not in use and that expired medications should not be used, highlighting a failure to adhere to these protocols.
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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) |
|---|---|---|---|---|
| Vi At Grayhawk, A Vi And Plaza Companies Community | 2.9 mi | ★★★★★ | 0 | 0 |
| Shea Post Acute Rehabilitation Center | 4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Scottsdale | 4.2 mi | ★★★★★ | 9 | 0 |
| Vi At Silverstone, A Vi And Plaza Companies Commun | 4.6 mi | ★★★★★ | 0 | 0 |
| Advance Health Care Of Scottsdale | 4.7 mi | ★★★★★ | 3 | 0 |
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