Inspection Reports for
Scottsdale Village Square

The investigation was complaint-driven, involving substantiated incidents of physical abuse between Resident #1 and Resident #2, and between Resident #3 and her husband (visitor). The husband was banned temporarily and visits were supervised. Resident #2 was placed on 15-minute checks after an altercation. Multiple staff interviews confirmed awareness and reporting of abuse incidents.

The facility failed to protect three residents from physical abuse by other residents and a family member. Multiple incidents of resident-to-resident and resident-to-visitor physical abuse were documented, including altercations resulting in injuries and emotional distress. Staff and administration responded with interventions such as supervision, separation, and reporting, but abuse incidents occurred.

The following deficiencies were found during the on-site investigation of complaint 00153979,00154492, and 00154507 conducted on December 30, 2025:

The inspection found one deficiency involving failure to notify the Department immediately of a change in the facility manager. This repeated deficiency posed a risk as the Department was unaware if the facility maintained a qualified manager.

A $3,000.00 penalty was assessed and paid in full on 26 November 2025.

The complaint investigation was substantiated with multiple resident-to-resident abuse incidents documented between December 5 and December 22, 2025. Several residents were involved as alleged victims and perpetrators. The facility conducted 5-day investigations for each incident and implemented supervisory checks and behavioral interventions.

The facility failed to protect residents from abuse by other residents, with multiple altercations documented between residents resulting in injuries ranging from abrasions to fractures. The facility's investigations confirmed these incidents met the definition of abuse and failed to meet facility expectations.

The complaint investigation found substantiated incidents of resident-to-resident physical abuse involving Residents #1, #2, #10, and #20. The facility's internal investigation confirmed the abuse, and staff interviews detailed the incidents and responses. The abuse was reported to appropriate parties including the administrator and family members.

The facility failed to protect four residents from abuse by other residents, resulting in multiple physical altercations with minimal harm. The incidents involved residents hitting, pushing, and causing injury to each other, with staff intervening and separating residents. The facility's investigation confirmed the incidents and identified risks related to psychosocial well-being.

The complaint investigation substantiated multiple incidents of resident-to-resident abuse occurring on October 20, 21, 29, and November 3, 2025. The incidents involved physical strikes and verbal assaults with no immediate physical injuries noted, but one resident (#20) later suffered a fractured hip requiring hospitalization. The facility's response and supervision were found inadequate to prevent ongoing abuse.

The facility failed to protect residents from abuse by other residents, with documented incidents of physical and verbal altercations between residents #10, #8, #20 and their respective alleged perpetrators. The incidents resulted in minimal harm but demonstrated failure to meet facility expectations and regulatory requirements for resident safety and abuse prevention.

The following deficiencies were found during the on-site investigation of complaints 00149527, 00149519, and 00148869 conducted on November 4, 2025.

The inspection found eight deficiencies related to personnel verification, CPR certification, service plan documentation, medication storage, and medical record authentication. The deficiencies posed risks to resident safety and care verification.

A $1,400.00 penalty was assessed and paid in full on 28 November 2025.

The following deficiencies were found during the on-site investigation of complaints 00147436, 00146895, 00144382, 00143408, 00138894, 00144250, and 00147612 conducted on October 14, 2025.

This inspection found ten deficiencies related to staff training, policy implementation, documentation, and medication administration. Several deficiencies were repeats from prior inspections.

The complaint investigation found that two residents (#14 and #28) engaged in a physical altercation on September 6, 2025, resulting in injuries to both residents and a CNA. The incident was substantiated by video evidence and staff interviews.

The facility failed to protect residents from physical abuse during a resident-to-resident altercation that resulted in minor injuries to both residents and a Certified Nursing Assistant. Video footage and staff interviews confirmed the incident and inadequate staffing during the event.

The following deficiencies were found during the on-site investigation of complaints 00141555, 00143315, 00143321, and 00139050 conducted on September 5, 2025.

The inspection found four deficiencies related to management certification, personnel record maintenance, service plan updates, and vaccination notification documentation. The deficiencies posed risks including noncompliance with licensing requirements and potential health risks to residents.

The complaint investigation was substantiated as the resident left the facility without authorization, and the facility failed to notify the guardian or follow proper sign-out procedures. The resident was found later by emergency services after being reported missing and a police report and Silver Alert were issued.

The facility failed to ensure adequate supervision and proper documentation for resident #10, resulting in the resident leaving the premises without signing out and being at risk. The facility lacked proper paperwork for guardianship in the medical record and did not follow policies requiring verification of responsible parties before allowing residents to leave.

The complaint investigation involved multiple residents (#7, 24, 29, 31, 36, 43, 51, 57, 59, 67, 75, 111, 113, 114, 115, 117, 118, 125, 129, 130, 138, 182) with documented incidents of resident-to-resident abuse including punching, biting, hitting, and throwing objects. The facility failed to report and investigate these incidents timely and adequately. The Administrator and abuse coordinator acknowledged these altercations as abuse requiring reporting.

The facility failed to protect residents from physical abuse by other residents, with multiple documented resident-to-resident altercations involving physical aggression. The facility also failed to timely report suspected abuse and failed to maintain accurate and complete documentation of abuse incidents and resident assessments.

No deficiencies were found during the on-site investigation of complaint 00135132 conducted on July 3, 2025.

No deficiencies were found during the inspection.

One deficiency was found related to the treatment of residents with dignity and respect. No evidence text was provided for the deficiency.

The complaint investigation found that resident #91 physically abused resident #87 by hitting him on the left ear after resident #87 ate resident #91's cookie. The abuse was confirmed by staff interviews and progress notes. Resident #91 was placed on one-on-one supervision and medication review.

The facility failed to ensure resident #87 was protected from abuse by resident #91, who physically struck resident #87 after resident #87 ate resident #91's cookie. Staff intervened to separate the residents, and resident #91 was placed on one-on-one supervision with medication review planned.

The complaint investigation revealed multiple incidents of resident-to-resident abuse involving residents #67, #17, #97, #111, #77, and #50 as perpetrators and residents #41, #14, #83, #36, #84, #21, and #2 as victims. Investigations included interviews with staff and residents, progress notes, care plans, and facility policies. Some incidents involved sexual abuse, physical aggression, and verbal abuse. The facility's interventions and care plans were reviewed and found insufficient to prevent these incidents.

The facility failed to protect residents from physical and sexual abuse by other residents, with multiple documented incidents of resident-to-resident altercations resulting in physical harm and emotional distress. The facility also failed to provide adequate supervision for a resident at risk for aggressive behavior, leading to preventable accidents and injuries.

The complaint investigation involved an incident on May 30, 2025, where resident #13 punched resident #27 in the right eye. The facility's investigation found both residents lacked intent to cause harm. Resident #13 exhibited verbal and physical aggression and was monitored with interventions including 1 on 1 support and behavioral assessments.

The facility failed to ensure resident #27 was protected from abuse by resident #13, resulting in physical harm evidenced by discoloration to resident #27's right eye. The facility investigation concluded both residents lacked intent to cause harm, and the facility continued to follow policies related to behavioral management and abuse reporting.

The complaint investigation was unsubstantiated due to conflicting nonsensical recollections from the involved residents. Resident #81 reported being hit by Resident #76 resulting in a skin tear. The facility conducted interviews and a review of policies related to abuse and resident rights.

The facility failed to ensure one resident did not abuse another, resulting in a skin tear injury. The investigation was unsubstantiated due to conflicting resident statements, but evidence of the altercation was found including a skin tear and staff interviews.

No deficiencies were found during the on-site investigation of complaints 00131745 and 00131920 conducted on May 28, 2025.

No deficiencies were found during the complaint investigation.

Two deficiencies were found related to tuberculosis screening and medication administration compliance. No evidence text was provided for either deficiency.

A $500.00 penalty was assessed and paid in full on 29 May 2025.

A $250.00 penalty was assessed and paid in full on 17 April 2025.

No deficiencies were found during the on-site investigation of complaint 00108797 conducted on February 21, 2025.

No deficiencies were found during the inspection.

An on-site investigation of complaint AZ00223001 was conducted on February 10, 2025, and no deficiencies were cited.

No deficiencies were cited during this inspection.

The complaint investigation involved multiple residents (#44, #33, #70, #180) with substantiated findings of resident-to-resident abuse. The investigation included interviews with residents, staff, and review of care plans and progress notes. The abuse was considered minimal harm but involved physical altercations and emotional distress.

The facility failed to ensure residents were free from abuse, with documented incidents of resident-to-resident physical altercations causing injuries and emotional distress. Staff interviews revealed inconsistent monitoring and supervision, and some residents exhibited aggressive behaviors requiring close observation.

An on-site investigation of complaint AZ00222800 was conducted on January 30, 2025, and the following deficiency was cited.

The inspection found one deficiency involving failure to ensure a resident was treated with dignity, respect, and consideration. The deficiency involved inappropriate sexual behavior by a staff member toward a resident.

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00219208 conducted on January 16, 2025 and completed on January 17, 2025.

Two deficiencies were found related to tuberculosis infection control documentation and medication administration compliance. The facility failed to provide required TB screening documentation for multiple residents and improperly administered medication contrary to physician orders.

The complaint investigation substantiated that two residents eloped from the facility due to inadequate supervision and door security failures. Both residents were found and returned by police with no injuries. Staffing shortages and door maintenance issues were noted as contributing factors.

The facility failed to ensure adequate supervision to prevent elopement of two residents, resulting in both residents leaving the facility unsupervised and requiring police intervention to return them safely. Door security issues and insufficient staffing were identified as contributing factors.

The complaint investigation substantiated that resident #26 physically abused resident #32. The facility also failed to administer medications timely to multiple residents and failed to prevent elopement of resident #100 due to door alarm malfunction and supervision lapses.

The facility failed to prevent resident-to-resident abuse involving resident #26 and #32, failed to administer medications within the required timeframe to six residents, and failed to prevent elopement of resident #100 due to malfunctioning door alarms and inadequate supervision.

The complaint investigation found that resident #3 was physically hit and injured by resident #4, who was aggressive and agitated. Both residents had abrasions and were separated by staff. Resident #4 was transported out by emergency services. Staff interviews confirmed the altercation and inadequate supervision.

The facility failed to ensure adequate supervision to prevent abuse between residents #3 and #4, resulting in physical altercations causing minor injuries. Staff interviews and clinical record reviews confirmed incidents of verbal and physical aggression, with resident #4 being transported out after aggressive behavior.

The investigation was complaint-driven, focusing on psychotropic medication consent and PASRR referral compliance. Resident-to-resident altercations were noted but not the primary complaint. The complaint was substantiated with findings of deficient practices.

The facility failed to ensure that resident #2 and/or representative were informed of the risks and benefits of psychotropic medications prior to administration, and failed to refer resident #1 with mental illness to the appropriate state-designated mental health authority for review. Both deficiencies posed potential minimal harm to residents.

The complaint investigation found that resident #200 exhibited wandering and elopement behaviors over several days, culminating in the resident leaving the facility on September 9, 2024, through a window without an alarm. The resident was found by police about a block from the facility with minor injuries. The facility's elopement risk assessment indicated no risk, and no care plan was in place to address wandering behaviors. Interviews with staff confirmed lack of adequate supervision and preventive measures.

The facility failed to ensure adequate supervision for one resident (#200) with wandering and elopement behaviors, which led to the resident leaving the facility through a window and sustaining minor injuries. Despite documentation of wandering behaviors, no care plan interventions were implemented to address the risk, and the resident was not identified as at risk for elopement based on the facility's assessment tool.

A $750.00 penalty was assessed and paid in full on 23 October 2024.

The investigation was complaint-driven based on multiple allegations of resident-to-resident abuse, including sexual abuse incidents involving residents #40, #25, #5, #6, and #49. The facility failed to report some incidents to the State Agency and law enforcement and failed to adequately investigate and intervene.

The facility failed to protect residents from abuse by other residents, failed to report allegations of abuse to appropriate authorities timely, failed to conduct thorough investigations of abuse allegations, and failed to maintain adequate staffing levels to ensure resident safety and supervision.

The complaint investigation was substantiated. Resident #625 was found to have assaulted resident #650 after a verbal altercation. The facility investigation confirmed the incident with witness statements and staff interviews. No injuries were sustained by either resident, and the primary care provider had no new recommendations.

The facility failed to protect resident #650 from abuse by resident #625 during a resident-to-resident altercation. The investigation substantiated the allegation with minimal harm and few residents affected. Additionally, the facility failed to ensure proper infection control practices during a COVID-19 outbreak, including failure to wear masks by staff and visitors.

The complaint investigation was triggered by anonymous reports and resident allegations of sexual and physical abuse by a certified nurse assistant (CNA #66) and resident-to-resident inappropriate sexual behavior. The facility failed to report these allegations to the State Agency or law enforcement and did not complete adequate follow-up or investigations.

The facility failed to protect residents from sexual and physical abuse by staff and other residents, resulting in immediate jeopardy and psychosocial harm. The facility also failed to report allegations of abuse to appropriate authorities and did not thoroughly investigate the allegations. Several residents exhibited behavioral issues and cognitive impairments complicating the incidents.

An on-site investigation of complaints AZ00210211, AZ00212462, and AZ00213997 was conducted on August 1, 2024, resulting in ten deficiencies cited.

The inspection found ten deficiencies related to failure to notify the Department of a manager change, incomplete personnel record compliance, inadequate documentation of abuse prevention actions, lack of caregiver verification and orientation, incomplete resident service plans, improper resident relocation consent, and medication administration not compliant with orders.

Complaint investigation regarding failure to notify family of injury to resident #7. The complaint was substantiated as the family was not notified as required.

The facility failed to ensure that the family of resident #7 was notified of the injury sustained on March 19, 2024, despite facility policy requiring such notification. Documentation showed no evidence that the family was informed, and staff interviews confirmed the lack of notification.

The complaint investigation found substantiated resident-to-resident abuse incidents on February 27, 2024 and April 18, 2024. The facility did not update care plans promptly after the first incident and did not separate residents immediately. Psychological evaluation and safety measures were implemented after the second incident.

The facility failed to ensure that one resident was not abused by another resident, resulting in physical and psychological harm. Despite incidents occurring in February and April 2024, care plans were not promptly updated to address the behaviors, and residents were not immediately separated after the first altercation.

An on-site investigation of complaint AZ00208776 was conducted on April 10, 2024, and the following deficiencies were cited.

The inspection found three deficiencies related to failure to verify fingerprint clearance cards, improper use of restraints on a resident, and lack of required medical determinations for a resident unable to ambulate. These deficiencies posed health and safety risks to residents.

An on-site investigation of complaint AZ00205553 and AZ00205671 was conducted on February 5, 2024, and the following deficiencies were cited.

The inspection found one deficiency related to failure to document services provided in a resident's medical record, posing a health and safety risk.

The complaint investigation involved an incident on December 23, 2021, where resident #26 was found with a laceration to the forehead after entering resident #28's room and being hit with a television remote. Both residents were separated and assessed. The facility submitted a self-report but failed to conduct a complete and thorough investigation, lacking interviews and evidence documentation. The incident was reported late to Adult Protective Services and the State Agency.

The facility failed to ensure one resident (#26) was free from abuse by another resident (#28). The investigation into the incident was incomplete and lacked thorough documentation, including missing interviews and evidence collection. The facility also failed to fully implement their abuse investigation policy, which could result in abuse not being properly identified or addressed.

The complaint involved allegations of abuse between residents #2 and #21, and residents #27 and #38. The facility investigation did not include staff interviews and was incomplete. The Director of Nursing stated that the investigation lacked thoroughness and that failure to interview all involved parties could lead to further incidents. The abuse was substantiated as resident #27 was found to have physically abused resident #38 and others.

The facility failed to prevent and properly investigate incidents of resident-to-resident abuse involving residents #2, #21, #27, and #38. Multiple altercations occurred, including physical assaults such as hitting and punching. Staff monitoring and investigation procedures were found deficient, with some staff not present or not intervening timely. The facility's investigation lacked comprehensive staff interviews.

A $750.00 penalty was assessed and paid in full on 23 March 2023.

The facility was found deficient in timely completion and submission of Minimum Data Set (MDS) assessments, provision of adequate personal care and bowel care for residents, pressure ulcer prevention and treatment, staff training on dementia and abuse prevention, medication regimen review follow-up, quality control of glucometers, completeness of medical records including therapy and PASRR documentation, pneumococcal vaccination education and offering, COVID-19 staff vaccination compliance, and daily staff posting.

The visit was complaint-related due to allegations of resident-to-resident abuse and failure to report abuse incidents timely. The investigation found substantiated incidents of physical abuse and failure to report within required timeframes.

The facility failed to ensure residents were free from physical abuse by other residents, failed to timely report allegations of abuse to the State Agency within 2 hours, and failed to revise care plans regarding hearing aids for one resident. Additionally, the facility failed to provide education and obtain signed consent for influenza vaccinations for several residents.