Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vi At Silverstone, A Vi And Plaza Companies Commun during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed rate after surveyors observed two errors in 25 opportunities. An LPN gave a resident metoprolol ER 50 mg instead of the ordered 25 mg dose after the order had been changed, and also crushed a resident's Slow Fe ER medication despite it being an extended-release tablet. The DON and pharmacy manager confirmed the ordered doses and formulation requirements, and the MAR and progress notes documented the variance.
The facility failed to document emergency preparedness training for a dietary server, a PTA, and a speech therapist. Records reviewed by surveyors did not show the required training for these staff members, and interviews with the DON and HRD confirmed gaps in the transcripts and uncertainty about completion for some employees. The facility policy stated that new and existing staff, volunteers, and contractors were to receive required training on key topics, including resident rights, abuse, dementia management, and infection control.
Missing annual resident rights training was identified for a dietary server, a PTA, and a speech therapist. Facility records did not show resident rights training for these employees, and the DON and HRD gave differing accounts about required training for dietary, therapy, and contracted staff. The facility policy stated that all new and existing staff, volunteers, and contractors are to receive training on resident rights and facility responsibilities.
Missing Required Abuse and Dementia Training for Staff: The facility failed to ensure that two staff members, including a dietary server and an ST, had documented annual training on abuse, neglect, and exploitation. Surveyors found that the staff transcripts did not show completion of required topics, while the DON stated that staff are expected to complete annual modules covering abuse, resident rights, infection control, emergency preparedness, and dementia care. The HRD stated that the dietary server was not required to have abuse and infection control training, and the ST’s transcript did not list several orientation topics the ST said she had completed.
The facility failed to ensure annual infection control training was completed and documented for a dietary server, a lifestyle manager, a physical therapy assistant, and a speech therapist. Review of transcripts showed missing infection control entries for several staff, and a later-submitted document for the lifestyle manager showed training completion but still no infection control training for the following year. The DON said infection control was part of annual staff education, while the HRD acknowledged that multiple staff transcripts did not show the required training.
The facility failed to ensure that multiple staff members received required annual behavioral health training related to dementia care. A Dietary Server, a PTA, and a Speech Therapist had transcripts that did not show the required dementia-related training, and one staff member’s transcript also lacked other required orientation topics such as abuse, infection control, EJA, resident rights, and emergency preparedness. Interviews with the DON and HRD confirmed that these trainings were expected for staff, including therapy and dietary personnel, and the facility policy required training on resident rights, abuse, neglect and exploitation, dementia management, and infection control.
Failure to develop and implement a rehab care plan for a resident with hemiplegia, weakness, and impaired mobility. The resident had an active PT/OT order, but PT was discontinued, no OT eval or treatment plan was documented, and the care plan lacked contracture prevention and management interventions. The resident was observed with a contracted, foul-smelling left hand without a splint, hand roll, carrot, or brace, and staff confirmed no contracture monitoring or OT recommendations were in place.
Care Plan Not Updated for OT Services: A resident with hemiplegia, hemiparesis, muscle weakness, and impaired mobility had an OT eval-and-treat order, but OT was not completed and the care plan was not revised to reflect the service. The resident reported not receiving therapy for a long period of time and was observed with a contracted left hand, foul odor, and debris under the fingernails. Staff and the DON confirmed there were no OT notes in the record and the care plan had not been updated.
Failure to provide nail and hand care for a resident with hemiplegia, hemiparesis, and significant ADL dependence. The resident was observed with long fingernails, debris under the nails, a contracted hand with a fingernail pressing into the palm, and a strong odor from the hand; the resident stated staff had not provided nail care during bed baths. Staff and the DON confirmed nail care and hand cleansing were part of routine care and that the resident required extensive assistance with personal hygiene.
A resident with hemiplegia, weakness, gait impairment, and a contracted hand had active PT and OT eval-and-treat orders, but OT was never completed. The resident was observed in bed with the left hand tightly contracted and reported not receiving therapy for an unknown period of time, while chart review showed no OT services and no care plan update for the ordered OT. The DOR, PT, and DON all confirmed the OT order was not carried out and that communication between nursing and therapy was lacking.
Failure to Provide Ordered PT/OT Services: A resident with hemiplegia, weakness, and impaired mobility had a PT/OT eval and treat order, but only PT was provided and no OT eval or treatment was completed. The resident reported not receiving therapy since admission and was observed with a left hand contracture and no carrot or washcloth in place. Staff interviews confirmed the OT service was missed, no formal contracture management plan was documented, and the DON stated the facility missed the resident’s contracture and had no contracture monitoring sheets or care plan interventions.
A resident’s electronic chart contained two DNR advance directive forms that did not match the resident’s DOB and were not consistent with the resident’s full code status. Staff confirmed the resident was full code, the DNR form should not have been in the chart, and the DON and medical record staff identified that the documents belonged to the wrong resident.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent after surveyors observed 2 medication errors out of 25 opportunities, resulting in an 8 percent error rate. The deficiency involved medication administration observations, clinical record review, staff interviews, and review of facility documents and policy. One resident had diagnoses including Alzheimer's disease, dementia, anxiety, atrial fibrillation, dysphagia, and cognitive communication deficit, and had a BIMS score of 3 indicating severe impairment. The resident's physician order had been changed from metoprolol succinate ER 50 mg twice daily to 25 mg twice daily, with the 50 mg order discontinued. During medication administration observation, an LPN prepared and administered metoprolol succinate ER 50 mg instead of the ordered 25 mg dose. The MAR reflected the updated 25 mg order, and a progress note later documented a medication variance stating that 50 mg was given instead of 25 mg as ordered. A second resident had diagnoses including acute cystitis with hematuria, dementia, depression, hypertension, cognitive communication deficit, and weakness. During medication administration observation, the same LPN stated that the resident's medications were crushed except for a probiotic capsule, and that she mixed the medications in applesauce. The resident had an order for Slow Fe 137 mg ER once daily, which is an extended-release medication. The pharmacy manager stated that Slow Fe should not be crushed because it is extended release and that iron also comes in liquid form. The report also included an interview in which the LPN acknowledged giving the incorrect metoprolol dose and described checking the MAR against the medication card, while the DON stated that staff should follow the electronic MAR and physician orders.
Missing Emergency Preparedness Training for Multiple Staff
Penalty
Summary
The facility failed to ensure that staff members #44, #168, and #182 received training on emergency preparedness. During review of staffing and transcript records on 5/28/2026, the emergency preparedness training was not listed for the Dietary Server, the Physical Therapy Assistant, or the Speech Therapist, and the records did not show when each staff member completed the annual training. The Dietary Server was hired on 12/16/2024, and the transcript history for 2025 did not show emergency preparedness training. The Physical Therapy Assistant was hired on 08/01/2024, and the transcript document did not list emergency preparedness training. The Speech Therapist was hired on 01/05/2026, and her 2026 transcript did not list emergency preparedness training; the transcript also showed other modules started on 03/30/2026, 04/01/2026, 04/22/2026, 04/23/2026, and 05/06/2026. During interviews, the DON stated that staff complete annual training through eCampus and weekly meetings, and that emergency preparedness training is included twice a year. The HRD stated that the facility expected contracted rehabilitation staff to receive the same training as facility staff, but he did not see emergency preparedness training listed for Staff #168 or Staff #182. The facility policy titled Staff Development and Orientation-Resident Care stated that all new and existing staff, volunteers, and contractors would receive training on resident rights, abuse, neglect and exploitation, dementia management, and infection control.
Missing Annual Resident Rights Training for Multiple Staff
Penalty
Summary
The facility failed to ensure that three staff members received annual training on resident rights. Review of the staffing list and transcript histories showed that the dietary server, the physical therapy assistant, and the speech therapist did not have resident rights training listed in their records. For the dietary server and the physical therapy assistant, the facility could not verify when the annual resident rights training had been completed. For the speech therapist, the transcript also did not list resident rights training, and the transcript showed other modules were started on several later dates. During an interview, the DON stated that the facility uses an eCampus for annual module training and weekly meetings for additional topics, including resident rights, abuse and neglect, infection control, emergency preparedness, and dementia care. She stated that the therapy team and dietary staff take the same training as nursing staff and that she expects staff to complete required training modules. The HRD stated that the dietary server had a different learning plan and was not required to have abuse and infection control training, and also stated that the contracted rehabilitation company should provide its employees the same training as the facility provides to its employees. The facility policy titled Staff Development and Orientation-Resident Care, revised 10/2023, stated that all new and existing staff, volunteers, and contractors will receive training on resident rights and facility responsibilities, abuse, neglect and exploitation, dementia management, and infection control. The speech therapist stated that she had received orientation training that should have included abuse, infection control, Elder Justice Act, emergency preparedness, and resident rights, and that there should be a transcript documenting it; however, the transcript reviewed did not list those trainings.
Missing Required Abuse and Dementia Training for Staff
Penalty
Summary
The facility failed to ensure that two staff members received annual training on abuse, neglect, and exploitation. On 5/28/2026, surveyors requested training records for a Dietary Server and a Speech Therapist. The Dietary Server’s 2025 transcript did not list abuse, neglect, and exploitation training, and the record did not show when that annual training was completed. The Speech Therapist’s 2026 transcript also did not list abuse, neglect, and exploitation training, and the record did not show when that training was completed. During an interview, the DON stated that staff receive annual module training through eCampus and additional topics during weekly meetings, including abuse, resident rights, infection control, emergency preparedness, and dementia care. She stated that the therapy team and dietary staff take the same training as nursing staff and that she expects staff to complete their required modules. The Administrator stated that therapy employee files were not kept on site and would need to be obtained through the therapy company. The Speech Therapist stated that she had received orientation training by video and believed there should be a transcript showing completion of abuse training, infection control, Elder Justice Act, emergency preparedness, and resident rights training. However, her transcript did not list those topics, and it showed modules on other subjects beginning later in the spring. The HR Director stated that the Dietary Server was not required to have abuse and infection control training, and also stated that the contracted rehabilitation company should provide its employees the same training as the facility provides. The facility policy stated that all new and existing staff, volunteers, and contractors will receive training on resident rights, abuse, neglect and exploitation, dementia management, and infection control.
Missing Annual Infection Control Training for Multiple Staff
Penalty
Summary
The facility failed to ensure that annual infection control training was completed and documented for four staff members: a dietary server, a lifestyle manager, a physical therapy assistant, and a speech therapist. Review of staffing records and training transcripts showed that infection control training was not listed for the dietary server, the physical therapy assistant, or the speech therapist, and it was not known when those staff members completed the required annual training. The lifestyle manager’s 2025 transcript also did not list infection control training, although an additional document later emailed to the State Agency showed a registration date of 01/04/2025 and completion of the infection control training on 05/06/2025; that document also showed no infection control training for 05/2026. During an interview, the DON stated that staff receive annual module training through eCampus and additional education during weekly meetings, and she identified infection control as one of the annual topics expected for staff. The DON also stated that she had access to staff modules to monitor completion. The HRD reviewed the transcripts and stated that the dietary server was not required to have infection control training, while also acknowledging that the lifestyle manager’s transcript did not show infection control training for 2025 and that the physical therapy assistant and speech therapist did not have infection control training listed in their transcripts. The speech therapist stated that she had received orientation training at the facility, including infection control, resident rights, emergency preparedness, Elder Justice Act, and abuse training, and that there should be a transcript showing completion. However, her 2026 transcript did not list those trainings, and it showed modules on other topics beginning later in March, April, and May 2026. The facility policy titled Staff Development and Orientation-Resident Care stated that all new and existing staff, volunteers, and contractors would receive training on topics including resident rights, abuse, neglect and exploitation, dementia management, and infection control.
Missing Required Dementia Care Training for Multiple Staff
Penalty
Summary
The facility failed to ensure that 3 staff members received annual behavioral health training related to dementia care. Staff #44, a Dietary Server hired on 12/16/2024, had no behavioral health training related to dementia care listed on the 2025 transcript history document, and it was not known when that training was completed. Staff #168, a Physical Therapy Assistant hired on 08/01/2024, also had no behavioral health training related to dementia care listed on the transcript document, and it was not known when that training was completed. Staff #182, a Speech Therapist hired on 01/05/2026, likewise had no behavioral health training related to dementia care listed on the transcript document. During the review of her 2026 transcript, no abuse, infection control, Elder Justice Act, emergency preparedness, or resident rights training was listed, and her transcript showed modules on other topics beginning on 03/30/2026, 04/01/2026, 04/22/2026, 04/23/2026, and 05/06/2026. Staff interviews confirmed that the facility expected staff to complete required training modules and that the DON had access to monitor completion. The DON stated that annual training included abuse, infection control, EJA, resident rights, emergency preparedness, and dementia care training, and that the therapy team and dietary staff took the same training as nursing staff. The HRD stated that Staff #168 completed abuse training in 12/2025 but did not see other required trainings for that staff member, and stated that Staff #182’s transcript did not show the required trainings. The facility policy titled Staff Development and Orientation-Resident Care stated that all new and existing staff, volunteers, and contractors would receive training on resident rights, abuse, neglect and exploitation, dementia management, and infection control.
Failure to Develop and Implement Rehabilitation Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for resident #5 regarding rehabilitation services. The resident was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and abnormalities of mobility and gait. A physician order dated February 5, 2026, included PT and OT to evaluate and treat, but no frequency or end date was included in the order. A care plan dated March 30, 2026 identified ADL self-care deficit related to impaired mobility and included PT and OT consultation and treatment per physician orders, but it did not include interventions related to contracture prevention, management, or OT recommendations. The quarterly MDS showed a BIMS score of 14, indicating intact cognition, and documented impairment of the resident's upper and lower extremities on one side with substantial or maximal assistance needed for bed mobility and transfers. The MDS also indicated the resident was not receiving PT or OT services during the lookback period. During an initial screening, the resident was observed lying in bed with the left hand contracted and fingers tightly curled into the palm. The resident stated she was supposed to receive therapy but had not received it for a period of time, could not recall how long, was unable to get out of bed, unable to move, and had pain on the left side of her body including her left hand. On later observation, the resident's left hand was curved inward at the wrist with the fingers tightly clenched in a contracted position. The hand had a strong foul odor, no hand roll, splint, carrot, or brace, and dark debris was noted under the fingernails indenting into the palm. The resident stated she had not received therapy or restorative services for her left hand. Staff interviews confirmed PT had been discontinued, no OT evaluation or treatment plan was documented, the OT order remained active, and no contracture monitoring sheets or contracture prevention interventions were in the care plan. The DON stated the resident should have received an OT evaluation and contracture screening and confirmed there were no contracture prevention interventions in the care plan.
Care Plan Not Updated for OT Services
Penalty
Summary
The facility failed to ensure the comprehensive care plan for one resident was reviewed and revised to address occupational therapy services. The resident was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and abnormalities in mobility and gait. A physician order dated February 5, 2026, included PT and OT to evaluate and treat, but the order did not specify therapy frequency. A care plan dated March 30, 2026, included an ADL problem area related to impaired mobility and left-sided weakness, with approaches for physical assistance as needed and PT and OT consultation and treatment per orders. A quarterly MDS assessment showed a BIMS score of 14, dependence for bathing and showers, and substantial to maximal assistance needed for personal hygiene. During the look-back period, the resident was not receiving OT services. On May 26, 2026, the resident stated she was unable to move her left side, was no longer able to attend activities or get out of bed, and had not received therapy services for a long period of time. Observation showed her left hand was contracted inward with tightly clenched fingers, a strong foul odor from the hand, dark brown debris under both hands' fingernails, and no carrot, brace, or washcloth in place to prevent contracture. Staff review confirmed the OT order had not been completed and there were no OT notes in the progress notes or care plan. The DON stated the evaluation for OT had not been completed and the care plan had not been updated to include the new OT orders.
Failure to Provide Nail and Hand Care
Penalty
Summary
The facility failed to ensure proper nail care was provided for one resident who had hemiplegia, hemiparesis, muscle weakness, and impaired mobility and gait. The resident’s care plan identified an ADL self-care deficit related to impaired functional mobility and required assistance with ADLs, and the MDS showed intact cognition, impairment of one side’s upper and lower extremities, dependence for bathing and showers, and substantial to maximal assistance with personal hygiene. During observations, the resident was found with long fingernails and dark brown debris underneath them, along with a strong odor of feces and disheveled, oily hair. The resident stated she had only received a bed bath and no showers, despite showers being scheduled twice weekly, and said staff had not provided nail care during bed baths. A later observation showed the resident’s left hand contracted, with the middle fingernail indenting the palm, long fingernails with debris on both hands, chipped nails, and a strong odor from the left hand. Staff interviews confirmed the resident required extensive assistance with care, that nail and hand cleansing should occur during bed baths and daily care, and that all nursing staff were responsible for ensuring the resident’s nails were clean. The DON stated nail care should be provided by all nursing staff during showers and daily care, and the facility policy included nail care as part of general nursing care.
Failure to Provide Ordered OT Services
Penalty
Summary
The facility failed to ensure one resident with hemiplegia, hemiparesis, muscle weakness, gait and mobility abnormalities, and polyneuropathy received occupational therapy treatment and services in accordance with physician orders and professional standards of practice. The resident had an order for PT and OT to evaluate and treat, and the care plan identified restorative PROM, fall risk, and impaired ADLs related to left-sided weakness, with PT and OT consult and treatment listed among the approaches. A quarterly MDS showed the resident needed substantial or maximal assistance with toileting and personal hygiene, was dependent for bathing, was always incontinent of bowel and bladder, and had pain indicators noted. During an initial screening, the resident was observed lying in bed with the left hand contracted and the fingers tightly curled into the palm. The resident stated she was supposed to receive therapy but had not received therapy for a period of time, could not recall how long, was unable to get out of bed, unable to move, and had pain on the left side of her body including the left hand. Review of the record showed the resident was not receiving OT services, and a nurse reviewing the chart stated there was no documentation or update to the care plan regarding the ordered OT evaluation and treatment. The DOR stated the resident received PT from February through April 2026, but no OT evaluation was completed despite the active OT order from February 2026. The DOR also stated there was a lack of documentation confirming communication about OT services due to staffing changes in the therapy department. The PT stated OT addresses upper extremity function and contracture-related interventions, while the DON stated therapy orders should be implemented once written, nursing must notify therapy of new orders, and the resident should have received OT for contracture management. The DON further stated the resident was admitted with a contracture and the facility missed it by not implementing the interventions, and there were no contracture monitoring sheets or care plan interventions for contracture prevention.
Failure to Provide Ordered Rehab Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered for one resident with hemiplegia and hemiparesis, muscle weakness, abnormal gait and mobility, and polyneuropathy. A physician order dated February 5, 2026 included PT and OT to evaluate and treat, but the record showed PT outpatient treatment only, with passive range of motion to the left upper and lower extremities from February 16, 2026 through April 16, 2026. During PT, the resident became upset and complained of pain, stating she never signed up for this and wanted it to stop, and the rehab manager was notified with PT planning discharge. Review of the record showed no OT evaluation or treatment was completed despite the active OT order. The resident’s care plan dated March 30, 2026 included restorative PROM to maintain joint function and prevent stiffness and atrophy, fall risk, and impaired ADLs related to left-sided weakness, with PT and OT consult and treatment listed among the approaches. The quarterly MDS showed a BIMS score of 14, substantial or maximal assistance for toileting and personal hygiene, dependence for bathing, and bowel and bladder incontinence. During the lookback period, the resident was not receiving PT or OT services. Interviews with the resident and staff confirmed the lack of OT services and the absence of documented contracture management. The resident stated she had not received therapy since admission and could no longer get out of bed or move her left side; observations showed a left hand contracture and later a strong odor from the left hand with no carrot or washcloth in place. Staff interviews confirmed no OT evaluation was completed, no formal contracture management plan was in place, and no orders were found for a carrot or washcloth. The DON stated the facility missed the resident’s contracture and that there were no contracture monitoring sheets or care plan interventions for contracture prevention.
Incorrect Advance Directive Filed in Resident Record
Penalty
Summary
The facility failed to maintain accurate documented medical records for one resident’s advance directives. Resident #3 was admitted with diagnoses including a displaced fracture of the upper end of the right arm, history of falling, syncope and collapse, low back pain, generalized muscle weakness, unsteadiness on feet, major depressive disorder, and anxiety disorder. The resident’s nursing progress notes and physician order identified the resident as full code, and the quarterly MDS showed a BIMS score of 15.0, indicating the resident was cognitively intact. A review of the resident’s electronic medical record under the Advance Directives tab showed two uploaded documents titled Advance Directive Form, both identified as State of Arizona Prehospital Medical Care Directive (Do Not Resuscitate). The documents contained a different date of birth than Resident #3’s date of birth. Staff interviews confirmed that the resident was full code and that the orange DNR form should not have been in the resident’s chart because it did not belong to the resident. Staff also stated that the resident’s code status was reflected as full code in the order, banner, and care plan. The LPN stated that advance directives are uploaded into the electronic record after admission and should match the resident’s information, including name and date of birth. The medical record coordinator stated that she checks the resident’s name and date of birth when uploading documents and that the advance directive should not have been present because the date of birth was incorrect. The DON also confirmed that Resident #3 was full code and that the DNR form was not filled out, while the facility policy required medical records to be confidential and maintained according to accepted standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 293 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Vi At Grayhawk, A Vi And Plaza Companies Community | 2.3 mi | ★★★★★ | 0 | 0 |
| Sante Of North Scottsdale | 4.6 mi | ★★★★★ | 0 | 0 |
| Acacia Health Center | 5.3 mi | ★★★★★ | 8 | 0 |
| Life Care Center Of Paradise Valley | 6.3 mi | ★★★★★ | 11 | 0 |
| Ridgecrest Post Acute | 6.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Vi At Silverstone, A Vi And Plaza Companies Commun.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.