Heritage Court Post Acute of Scottsdale

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to protect the rights of two out of the four sampled residents (Resident #18 and Resident #21) to be free from Physical abuse by another resident (Resident #11 and Resident #51). The deficient practice could result in the other residents being abused. Findings Include: -Regarding Resident #18 and Resident #11: Resident #18 was admitted to the facility on [DATE], with diagnosis of T Acute and Subacute Infective Endocarditis, Schizoaffective disorder, anxiety disorder, chronic viral hepatitis C, and other psychoactive substance abuse. Orders dated May 24, 2024, revealed orders for monitoring behavior every shift for anti-anxiety episodes, monitoring for side effects of antianxiety/anxiolytics, and monitoring side effects of pain medication. [...]

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to report allegations of abuse for one resident (#1). The deficient practice could result in allegations of abuse not being reported, not investigated, and residents not being protected from further abuse. Resident #1 was admitted on [DATE] with diagnosis included fracture of left femur, difficulty in walking, anxiety disorder, depression, anemia, and cerebral infarction. The Admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that resident is cognitively intact. Nursing note dated August 15, 2025 at 09:30AM revealed the patient informed, thinks she was gang raped by night staff. However, the incident was not reported to state agency. [...]

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure that one resident (#59) and/or their representative were informed of the risks and benefits of psychotropic medications prior to the administration of the medications. The sample size was 5. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and the potential adverse side effects of psychoactive medications.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews and policy review, the facility failed to ensure that one of one sampled resident's (#427) environment was free of accident hazards regarding medicated cream left at the bedside. This deficient practice could result in an adverse event for the resident.

Inspectors wroteBased on record review, facility documentation, staff and resident interviews and policy review, the facility failed to ensure two of three sampled residents (#426 and #427) with an indwelling catheter received a physician order for the catheter and catheter care. This deficient practice could lead to residents not receiving proper catheter care and the development of an infection.

Inspectors wroteBased on record review, facility documentation, staff and resident interviews and policy review, the facility failed to ensure that two of two sampled residents (#426 and #427) received appropriate respiratory care per physician orders. This deficient practice could lead to respiratory issues.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that residents were treated with dignity and respect. The deficient practice could result in residents being psychosocially effected.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a thorough investigation was completed for one resident (#22) alleging abuse. The deficient practice could result in residents being physically and psychosocial harmed.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#44) was administered medication as prescribed. The deficient practice could result in adverse effects of medications administered.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure adequate supervision was provided to one resident (#1) to prevent elopement. The deficient practice could result in injury or harm to the resident.

Inspectors wroteBased on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure one was resident (31) was not physically abused by another resident (#154).

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II was referred to the State designated authority for evaluation and determination and a PASRR Level I was completed for two residents (#170) and (#6). The universe is 54 and the sample size is 2. The deficient practice could result in specialized services not being identified and provided to residents.

Inspectors wroteBased on observations, clinical record review, interviews, and policy review, the facility failed to ensure one resident (#40) received the necessary services to maintain good grooming hygiene. This deficient practice could result in grooming needs not being met. A resident interview was conducted with resident (#40) on 11/14/23 at 10:24 AM. Resident (#40) stated he has not had a haircut since in the facility. Resident (#40) stated he dislikes the length of his hair and has requested a haircut multiple times throughout the year. Resident (#40) stated he informed the nursing staff of his request for a haircut, but was told that the facility does not offer those services. Resident (#40) stated there were a few CNA's who would cut the residents hair for them, but they are no longer work for the facility. [...]

Inspectors wroteBased on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that infection control standards were maintained during medication pass. This deficient practice could result in the spread of infection to residents. Resident #4 was admitted to the facility on [DATE] with diagnoses that included paraplegia, scoliosis, neurogenic bladder, anxiety, anemia and depression. An observation during medication pass was conducted on November 15, 2023 at 8:43 a.m. with an RN (Registered Nurse) (RN/staff #8). The RN was observed administering medications to resident #4. However, no hand hygiene was observed and the RN was observed removing gloves from his pocket and using them during the medication pass. In an interview with the RN (RN/staff #8) conducted on November 16, 2023 at 10:18 a.m. [...]

Inspectors wroteBased on review of the clinical record, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one section (L) of a Minimum Data Set (MDS) assessment for one resident (#28) accurately reflected his oral/dental status. The sample was 19 residents. The deficient practice could result in residents not receiving care and services for oral/dental conditions.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to monitor one resident's (#4) weight per physician's orders. The sample size was 5. The deficient practice could result in resident not receiving the needed services for change of condition.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure routine medication was consistently available for one resident (#28). The sample size was 6. The deficient practice could result in necessary medications not available and not administered to residents as ordered by the physician.

Inspectors wroteBased on the observation, clinical record review, staff interviews and policy review, the facility failed to ensure that out of date medication was discarded for one resident (#26). The deficient practice could result in ineffective treatment of diabetes.

Inspectors wroteBased on review of the clinical record, staff interviews, and review of facility policies and procedures, the facility failed to ensure that dental needs were met for one of one sampled residents (#28) . The deficient practice could result in residents not receiving care and services for oral/dental conditions.