Rehab at Scottsdale Village Square

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure wound was monitored and treated for 1 of 3 residents sampled for wound care (Resident #1). The deficient practice resulted in the development of maggots in the wound bed.

Inspectors wroteBased on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 2 of 6 residents sampled (#2, #3) to be free from physical and verbal abuse between residents. The deficient practice could result in resident injury, psychological, or behavioral harm as well as continued resident to resident abuse.

Inspectors wroteBased on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 10 of 11 residents sampled (#1, #2, #3, #4, #6, #7, #8, #9, #10, and #11) to be free from physical and verbal abuse between residents. The deficient practice could result in resident injury, psychological, or behavioral harm as well as continued resident to resident abuse.

Inspectors wroteBased on interviews, clinical record and policy review, the facility failed to update comprehensive care plans related to repeat resident to resident abuse and update individualized resident interventions for three of eleven residents sampled (#1, #2, and #4). The deficient practice could result in a plan of care that did not meet the resident's needs and lead to continued resident to resident abuse.

Inspectors wroteBased on clinical record review, staff interviews, review of facility documentation and policies, the facility failed to protect the rights of 3 residents (#3, #4, #7) to be free from physical abuse by other residents (#2, #5, #6). The deficient practice could result in further abuse of residents and appropriate action not taken. Findings Include:Regarding Resident #3 and Resident #2 incident:Resident #3 was admitted on to the facility on 2/20/2025 with diagnoses that included Dementia and Major Depressive Disorder. The Resident's care plan dated 5/21/2025, revealed that the resident had an impaired cognitive function or impaired thought processes related to Dementia. The Resident's Behavioral Care Plan progress notes with an effective of 2/17/2026, revealed that the Resident's current behavior included an adjustment to living in a skilled nursing facility. [...]

Inspectors wroteBased on the review of the clinical records, staff interviews, and review of facility's policy and procedure, the facility failed to ensure a PASRR Level 2 (pre-admission screening and resident review) was submitted for one residents (#2) to the appropriate state-designated authority . The deficient practice could result in residents' medically related social and emotional needs not being met.

Inspectors wroteBased on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of twelve of twelve residents sampled (#1, #3, #5, #7, #9, #2, #4, #6, #8, #10, #13, and #16) to be free from physical abuse from each other. The deficient practice could result in continued resident to resident abuse.

Inspectors wroteBased on interviews, clinical record and policy review, the facility failed to update comprehensive care plans related to individualized resident triggers so residents may attain the highest practical physical, mental, and psychosocial well-being for twelve of twelve residents sampled (#1, #3, #5, #7, #9, #2, #4, #6, #8, #10, #13, and #16) to be free from abuse from each other. The deficient practice could result in a plan of care that did not meet the resident's needs and lead to continued resident to resident abuse.

Inspectors wroteBased on staff interviews, facility documentation, and policy review, the facility failed to track, trend, and analyze the cause of resident-to-resident abuse and implement a measurable preventative action plan. The deficient practice could result in continued resident-to-resident abuse.

Inspectors wroteBased on interviews, clinical record and policy review, the facility failed to update behavioral health care plans related to individualized resident triggers so residents may attain the highest practical physical, mental, and psychosocial well-being for two residents (#8 and #9). The deficient practice could result in a plan of care that did not meet the resident's needs.

Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy, the facility failed to protect the rights of one Resident (#6) out of the three sampled residents to be free from abuse by staff. The deficient practice could result in other residents being abused.

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse was reported timely to required entities for one resident (#6). The deficient practice could lead to ongoing abuse leading to harm of a resident.

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse investigation report was submitted within 5 working days to the State Survey Agency for one resident (#6). The deficient practice could lead to ongoing abuse leading to harm of a resident.

Inspectors wroteBased on clinical record reviews, staff and resident interviews, and policy, the facility failed to protect the rights of 3 of 3 residents (#1, #2, #3) to be free from physical abuse by other residents and family members. The deficient practice could result in further abuse. Regarding a resident-to-resident altercation that involved Resident #1 and Resident #2. -Regarding Resident #1 Resident #1 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses of dementia, major depressive disorder, anxiety disorder, epilepsy, and bipolar disorder. The care plan dated November 06, 2025, had a focused care area for Resident #1, having a behavior problem related to taking things and flushing them down the toilet. [...]

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of four of eight sampled residents (#24, 15, 20, and 9) to be free from abuse by other residents (#20, 22, 11, 18). The deficient practice could lead to ongoing abuse, leading to harm to other residents.-

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of three of seven sampled residents (#10, #8, and #20) to be free from abuse by other residents (#22, 16, and 6). The deficient practice could lead to ongoing abuse, leading to harm of other residents.-

Inspectors wroteBased on clinical record review, staff interviews, review of facility documentation and policies, the facility failed to protect the rights of four residents (#1, #2, #10, and #20) to be free from abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken.

Inspectors wroteBased on clinical record review, staff and resident interviews, and facility policy, the facility failed to protect the rights of two out of the four sample residents to be free from abuse by another resident. The deficient practice could result in other residents being abused. Regarding a resident-to-resident altercation that involved Resident # 50 and Resident #55. -Regarding Resident #50Resident # 50 was admitted to the facility on [DATE], with diagnoses of Bipolar Disorder, Alzheimer's Disease, and Anxiety. Orders dated May 24, 2025, revealed an order for Chlorpromazine HCL Oral Tablet 25 MG given for behaviors relating to Bipolar Disorders. Orders dated July 31, 2025, revealed an order for sertraline HCL oral Tablet 50 mg given for depression. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect residents' rights to be free from physical abuse for two of three sampled residents (#28 and #14). The deficient practice could result in psychosocial or physical harm to residents. -Regarding resident #14 Resident #14 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, bipolar disorder, hyperlipidemia, type 2 diabetes, mood affective disorder, anxiety disorder, benign prostatic hyperplasia, depression, hypertension, gastro-esophageal reflux disease, and insomnia. An Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. A behavior progress note dated September 6, 2025 at 12:15 p.m. [...]

Inspectors wroteBased on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure adequate supervision was provided to one resident (#10). The deficient practice resulted in placing resident's safety at risk with a non-authorized person.

Inspectors wroteThe facility failed to ensure advanced directives were accurately completed and maintained for two residentsNumber of residents sampled: 2Number of residents cited: 2Based on clinical record review, staff interview, and facility policy and procedure, the facility failed to ensure that the advance directives were consistent throughout for two of 103 sampled resident's (#66 & 86) clinical record. The deficient practice could result in residents receiving services that are not in accordance with their wishes.

Inspectors wroteFacility failed to store medications according to professional standards. Number of residents sampled:Number of residents cited: Based on observations, staff interviews, and a review of facility policies, the facility failed to ensure that expired medications were properly discarded and not available for use. Additionally, the facility failed to ensure medications for one resident (#17) were not left at the bedside. These deficient practices could result in residents receiving expired medications, and could result in resident injury, medication over-dose or contradictions. The facility census was 103.

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect residents' rights to be free from physical abuse for 22 residents (#129, #123, #67, #127, #124, #32, #24, #130, #75, #36, #7, #29, #51. #182, #57, #112, #114, #43, #115, #117, #118, #59). The deficient practice could result in psychosocial or physical harm to residents. Findings Include:-Regarding residents #57 and #29: Resident #57 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, encounter for palliative care, major depressive disorder, and dementia. Review of the care plan focus dated October 2, 2023 revealed that resident #57 had a behavior problem regarding dementia. Staff was to intervene as necessary to protect the rights and safety of others, remove resident #57 from situation, and take to an alternate location. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facilityfailed to ensure that the abuse policy was adhered to following an incident of resident-to-resident abuse for two residents (#111 and #24). The deficient practice could result in continued resident-to-resident abuse. -Regarding Resident #111 Resident #111 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), schizoaffective disorder, bipolar disorder, Asperger's syndrome, anxiety disorder, autistic disorder, and hypertension. A care plan focus initiated on March 8, 2023 revealed a behavior problem as evidenced by physical aggression and a history of peer altercations. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A progress note dated August 20, 2023 at 11: [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facilityfailed to ensure that an incident involving abuse between two residents (#111 and #24)was reported in a timely manner. The deficient practice could result in continued resident to resident abuse. -Regarding Resident #111 Resident #111 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), schizoaffective disorder, bipolar disorder, Asperger's syndrome, anxiety disorder, autistic disorder, and hypertension. A care plan focus initiated on March 8, 2023 revealed a behavior problem as evidenced by physical aggression and a history of peer altercations. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A progress note dated August 20, 2023 at 11:07 p.m. [...]

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to ensure that documentation was completed accurately for six residents (Residents #11, 43, 113, 114, 25 and 115) regarding abuse and resident assessment. This deficient practice could lead to incomplete documentation in residents' medical records.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#87) was not abused by another resident (#91). The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: Regarding resident #87: Resident #87 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, dementia, personality change due to known physiological condition, chronic ischemic heart disease, heart failure, hypertension, major depressive disorder, and anxiety disorder. A quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 08, indicating moderate cognitive impairment. A nursing progress note dated June 18, 2025 at 2:49 p.m. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that six residents (#67, #17, #97, #111, #77, and #50) did not abuse seven residents (#41, #14, #83, #36, #84, #21, and #2). The deficient practice could result in residents being physically harmed. -Regarding Resident #97 and Resident #84 Resident #97 was admitted on [DATE] with diagnoses that included vascular dementia, unspecified mood affective disorder, depression, intracranial hypertension, major depressive disorder, anxiety, adjustment disorder with mixed disturbance of emotions, and presence of cardiac pacemaker. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A nursing progress note dated August 30, 2022 at 3:59 p.m. [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#67) was provided with adequate supervision. The deficient practice could result in residents being subjected to preventable accidents and sustaining injuries.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#27) was not abused by another resident (#13). The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: -Regarding resident #27: Resident #27 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, hypertension, post-traumatic stress disorder, adjustment disorder with mixed disturbance of emotions and conduct, migraine, Alzheimer's disease, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 06, indicating severe cognitive impairment. A nursing progress note dated May 30, 2025 at 10:21 a.m. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#76) did not abuse another resident (#81). The deficient practice could result in residents being physically harmed.

Inspectors wroteBased on clinical record reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to ensure residents (#44, #33, #70 and #180) were free from abuse. The deficient practice could lead to further resident to resident abuse.

Inspectors wroteBased on observation, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that adequate supervision was provided to two residents (#13 and #22) to prevent elopement from the facility. The deficient practice can result in other residents to go missing and/or getting injured.

Inspectors wroteBased on observation, clincal documentation, staff interviews, and the facility policy and procedures, the facility failed to administer medications within the required timeframe to six residents (#66, #55, #12, #2, #15, and #25). The deficient practice could result in symptoms not being managed effectively and/or adverse effects.

Inspectors wroteBased on documentation, interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#26) did not abuse another resident (#32). The deficient practice could result in residents being physically and/or emotionally injured.

Inspectors wroteBased on facility documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident #100 did not elope from the facility. The deficient practice could result in residents eloping and being physically and/or emotionally harmed.

Inspectors wroteBased on observation, clinical record review, facility documentation and staff interviews, the facility failed to ensure that adequate supervision was provided to two residents (#3 and #4) to prevent abuse. The deficient prectice could increase the risk of resident to resident abuse.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure that resident (#2) and or representative was informed of the risks and benefits of psychotropic medications prior to the administration of the medications. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and the potential adverse side effects of psychotropic medications.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure one resident (#1) with a diagnosis of mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided for residents who need it.

Inspectors wroteBased on staff interviews, clinical record review, facility's documentation review, and facility policy review, the facility failed to ensure adequate supervision was provided for one resident (#200). The deficient practice resulted in resident wandering away and becoming lost in the community.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to protect the rights of one resident (#40) to be free from sexual abuse by another resident (#49); and, failed to protect the rights of two residents (#25 and #5) to be free from abuse by another resident (#6). The deficient practice could result in the potential for harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm.

Inspectors wroteBased on clinical record reviews, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to report allegations of abuse to the State Agency (SA), Adult Protective Services (APS) and local law enforcement for three sampled residents (#40, #25 and #5). The deficient practice could result in abuse not identified and investigated and place all residents at risk for further abuse.

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure an allegation of abuse for two residents (#40 and #36) by another resident (#49 and #25) were thoroughly investigated. The deficient practice could result in appropriate corrective action not taken to prevent further abuse.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure there was sufficient staffing to provide adequate supervision for multiple residents. The deficient practice could result in residents' not receiving the supervision needed to ensure resident safety.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#650) was free from abuse of another. The deficient practice could result in other residents being abused.

Inspectors wroteBased on observations, staff interviews, facility documentation, review of the Centers for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure infection control standards were followed by failing to ensure that Personal Protective Equipment (PPE) was donned. The deficient practice could result in the spread of infection, including COVID-19 to residents and staff.

Inspectors wroteBased on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to protect the rights of one resident (#23) to be free from sexual abuse and one resident (#3) to be free from physical abuse by a staff; and failed to ensure one resident (#45) by another resident (#9). The deficient practice resulted in psychosocial harm to resident #23 and had placed resident #3 and other residents at increased risk for further abuse, serious injury, harm and psychosocial harm. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The census was 100.

Inspectors wroteBased on clinical record reviews, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to report allegations of abuse to the State Agency, Adult Protective Services (APS) and local law enforcement for three residents (#23, #3 and #45). The sample was 3. The deficient practice could result in abuse not identified and investigated and place all residents at risk for further abuse.

Inspectors wroteBased on clinical record reviews, resident/staff interviews, facility documentation and policy review, the facility failed to ensure allegations of abuse was thoroughly investigated. The sample was 3. The deficient practice could result in residents at continued risk for further abuse.

Inspectors wroteBased on a closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure that a resident's representative was notified of an injury for one resident (#7). The deficient practice could result in resident representatives not being aware of the resident's injuries.

Inspectors wroteBased on facility documentation, staff interviews, and review of facility policy and procedures, the facility failed to ensure one resident (#1) was not abused by another resident (#2) The deficient practice could result in residents being physically and psychologically harmed.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure one resident (#26) was free from abuse of another. The deficient practice could result in other residents being abused.

Inspectors wroteBased on staff interviews, review of facility documentation, policy and procedures, the facility failed to implement their policy on abuse investigation for an allegation of abuse for one resident (#26). The deficient practice could result in abuse not identified and investigated.

Inspectors wroteBased on staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure a thorough investigation was completed for an allegation of abuse for one resident (#26). The deficient practice could result in appropriate corrective actions not taken.

Inspectors wroteBased on clinical record reviews, staff interviews, the Resident Assessment Instrument (RAI) manual, and facility policy, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required timeframes for 5 residents (#1, #3, #4, #5, and #8). The census was 91 residents. The deficient practice could result in delayed identification of potential risks and care needs.

Inspectors wroteBased on clinical record reviews, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments for six residents (#1, #3, #4, #5, #8, and #9) were transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completion. The deficient practice could result in resident specific MDS data for payment and quality measure purposes not being submitted as required.

Inspectors wroteBased on facility documentation, staff interviews, and facility policy, the facility failed to ensure that quality control testing was performed for one multi-use glucometer. The deficient practice could result in glucometers that do not function properly and therefore provide inaccurate glucose level results.

Inspectors wroteBased on clinical record review, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one resident (#9). The census was 91 residents. The deficient practice could result in delayed identification of potential risks and care needs.

Inspectors wroteBased on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident (#28) received adequate and consistent showers. The sample size was two residents. The deficient practice could result in residents' personal hygiene and grooming needs not being met.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one resident (#28) was provided adequate care and treatment related to bowel care. The sample size was two residents. The deficient practice could result in residents having discomfort and difficulty having a bowel movement.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#37) consistently received care to prevent pressure ulcers and was consistently provided pressure ulcer treatment. The sample size was 3. The deficient practice could result in the development of pressure ulcers, and delayed wound healing or worsening of a pressure ulcer.

Inspectors wroteBased on facility assessment review, personnel record reviews, staff interviews, and facility policy, the facility failed to provide dementia training for three staff members (#49, #72, and #5) and failed to provide resident rights training for one staff member (#5). The sample size was ten staff members. The deficient practice could result in inadequate care for the residents in the facility.

Inspectors wroteBased on clinical record reviews, and staff interviews, the facility failed to ensure that pharmacist reported irregularities were reviewed and acted upon for 2 residents (#49 and #37). The sample size was 5 residents. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation, the facility failed to ensure one resident's (#76) clinical record was complete regarding patient therapy records and Preadmission Screening and Resident Review (PASRR). The census was 91 residents. The deficient practice may result in residents' clinical records not being complete and accurate.

Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to ensure that one resident (#76) was provided education regarding the risks and benefits of pneumococcal immunization and failed to ensure the resident was offered the pneumococcal vaccine. The sample size was 5 residents. The deficient practice could result in residents not being informed of risks and benefits of pneumococcal immunization and could result in residents not being offered the vaccine.

Inspectors wroteBased on personnel record reviews, interviews, facility policy, and Centers for Medicare and Medicaid Services (CMS) interim final rule requirements, the facility failed to ensure 3 staff members (staff #17, #130, and #10) were vaccinated for COVID-19 or had approved exemptions. The census was 91 residents. The deficient practice could result in the spread of COVID-19 in the facility.

Inspectors wroteBased on personnel record review, a staff interview, and facility documentation, the facility failed to provide abuse training for one staff member (staff #49). The sample size was 10 staff members. The deficient practice could result in staff not being knowledgeable of how to prevent, identify, investigate, and report allegations of abuse.

Inspectors wroteBased on an observation, facility documentation, staff interviews, and facility policy, the facility failed to ensure daily staff posting was consistently displayed in a prominent place with the correct information. The census was 91 residents. The deficient practice could result in resident census information not being readily available to residents and visitors.