Inspection Reports for
Santé of Scottsdale

AZ, 85206

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22 Reports

13 state, 9 CMS 2021–2025

Inspection Report — Nov 25, 2025

Complaint Investigation State
Date: Nov 25, 2025

Visit Reason
On-site complaint investigation of complaints AZ00161381/2278158, AZ00168869/2278107, AZ00177824/2278172, AZ00177825/2278173, AZ00180497/2278181, AZ00182234/2278185, and AZ00183178/2278186 at a Nursing Care Institution, conducted 25 November 2025.

Complaint Details
The state risk based survey was conducted October 23, 2025 in conjunction with the investigation of complaints: AZ00161381/2278158, AZ00168869/2278107, AZ00177824/2278172, AZ00177825/2278173, AZ00180497/2278181, AZ00182234/2278185, and AZ00183178/2278186. There were no deficiencies noted.
Findings
No deficiencies were found during this complaint investigation.

Report Facts
Complaints investigated: 7

Inspection Report — Sep 11, 2025

State
Date: Sep 11, 2025

Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 11 September 2025.

Findings
The facility was found not in substantial compliance with Medicare/Medicaid Life Safety Code requirements at 42 CFR Subpart 483.90(a). One deficiency was cited related to cooking facilities, but no evidence text was provided.

Deficiencies (1)
Cooking facilities — No evidence text provided for the cited deficiency regarding protection of cooking equipment according to NFPA 96 standards.
Report Facts
Deficiencies cited: 1

Inspection Report — Jul 2, 2025

CMS
Date: Jul 2, 2025

Visit Reason
The inspection was conducted to evaluate the facility's compliance with resident rights and safety protocols, specifically regarding the implementation of a password protocol for visitation to protect residents from harm.

Findings
The facility failed to implement and properly document a password protocol for visitation to protect one resident (#634) with cognitive impairment and safety concerns. Interviews and record reviews revealed that the password protocol was not reflected in the resident's care plan or clinical record, and involved staff could not locate documentation of the protocol. This deficiency posed a risk of residents being further victimized.

Deficiencies (1)
Failure to implement and document a password protocol for visitation to protect resident #634 from harm.
Report Facts
Residents affected: 4 Residents affected: 1 Frequency of abuse training: 3

Employees mentioned
NameTitleContext
Certified Nursing Assistant (CNA) Staff #77Interviewed regarding visitation and abuse definitions
Assistant Director of Nursing (ADON) Staff #39Interviewed regarding visitation procedures
Licensed Practical Nurse (LPN) Staff #43Interviewed regarding abuse definitions
Director of Social Services (DoSS) Staff #10Interviewed regarding abuse training and password protocol documentation
Executive Director (ED) Staff #61Interviewed regarding password protocol documentation

Inspection Report — Oct 16, 2024

Complaint Investigation State
Date: Oct 16, 2024

Visit Reason
On-site complaint investigation of complaints AZ00216706 and AZ00216777 at a Nursing Care Institution, conducted 16 October 2024.

Complaint Details
The complaint survey was conducted on October 16, 2024 of the following complaint #'s AZ00216706 and AZ00216777. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.

Report Facts
Complaints investigated: 2

Inspection Report — Sep 11, 2024

Complaint Investigation State
Date: Sep 11, 2024

Visit Reason
On-site complaint investigation of complaints AZ00215637 and AZ00215738 at a Nursing Care Institution, conducted 11 September 2024.

Complaint Details
The onsite investigation of complaint AZ00215637 and AZ00215738 was conducted on September 11, 2024. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.

Report Facts
Complaints investigated: 2

Inspection Report — Sep 11, 2024

State
Date: Sep 11, 2024

Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted on 11 September 2024.

Findings
No deficiencies were found during this inspection. The facility met all applicable standards and requirements.

Inspection Report — Sep 6, 2024

Routine CMS
Date: Sep 6, 2024

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including timely notification of resident transfers or discharges, staffing requirements for registered nurses, and proper administration of medications.

Findings
The facility failed to notify the ombudsman of a resident transfer, did not ensure an RN was on duty for 8 consecutive hours on multiple days, and did not administer pain medication according to physician orders for one resident, potentially resulting in inadequate care and risk to residents.

Deficiencies (3)
Failed to notify the ombudsman of resident transfer or discharge.
Failed to ensure a Registered Nurse was on duty for 8 consecutive hours on multiple days.
Failed to administer pain medication according to physician's orders for one resident.
Report Facts
Oxycodone administrations below pain rating parameters in July 2024: 33 Oxycodone administrations below pain rating parameters in August 2024: 32

Employees mentioned
NameTitleContext
Staff #66Care Manager Licensed Practical Nurse (LPN)Provided information about resident #70's care plan and discharge process
Staff #167Care Manager Licensed Practical Nurse (LPN)Interviewed regarding emergency transfer of resident #70
Staff #172Social Services StaffStated unawareness of need to notify ombudsman
Staff #52Certified Nurse Assistant (CNA)Interviewed about typical resident care and communication
Staff #34Director of Nursing (DON)Interviewed about RN coverage and medication administration expectations
Staff #110Registered Nurse (RN)Interviewed about pain medication administration and assessment

Inspection Report — Sep 6, 2024

Annual Inspection State
Date: Sep 6, 2024

Visit Reason
On-site complaint investigation and annual compliance survey conducted September 3 through September 6, 2024, including investigation of complaints AZ00215422, AZ00193369, AZ00191191, AZ00189364, AZ00188462, AZ00191124, AZ00189363, AZ00188461, AZ00191190, AZ00193367, and AZ00198368 at a Nursing Care Institution.

Complaint Details
The state compliance and recertification surveys were conducted in conjunction with investigations of complaints AZ00215422, AZ00193369, AZ00191191, AZ00189364, AZ00188462, AZ00191124, AZ00189363, AZ00188461, AZ00191190, AZ00193367, and AZ00198368.
Findings
The inspection identified three deficiencies related to failure to notify the ombudsman of a resident discharge, lack of registered nurse coverage for eight consecutive hours on multiple days, and improper administration of pain medication outside physician orders. Plans of correction were provided for all deficiencies.

Deficiencies (3)
R9-10-408 — The facility failed to notify the ombudsman of the transfer or discharge of Resident #70, and documentation of discharge and ombudsman notification was missing.
R9-10-412 — The facility failed to ensure a registered nurse was present and providing direct care for eight consecutive hours on multiple days despite census ranging from 58 to 69 residents.
R9-10-412 — The facility failed to administer pain medication to Resident #15 according to physician's orders, with oxycodone given below the required pain rating multiple times without documentation or physician notification.
Report Facts
Deficiencies cited: 3

Employees mentioned
NameTitleContext
Staff #66Care Manager LPNInterviewed regarding discharge and ombudsman notification for Resident #70.
Staff #167Care Manager Licensed Practical Nurse (LPN)Interviewed about transfer of Resident #70 and discharge documentation.
Staff #172Social Services StaffInterviewed about awareness of ombudsman notification requirements.
Staff #52Certified Nurse Assistant (CNA)Interviewed about staffing and resident care.
Staff #34Director of NursingInterviewed about nurse coverage and medication administration.
Staff #110Registered NurseInterviewed about pain medication administration for Resident #15.

Inspection Report — Sep 6, 2024

Complaint Investigation CMS
Date: Sep 6, 2024

Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify the ombudsman of resident transfers or discharges, lack of required registered nurse coverage for 8 consecutive hours during the day, and improper administration of pain medication for a resident.

Complaint Details
The complaint investigation revealed that the facility failed to notify the ombudsman of a resident transfer or discharge, failed to maintain RN coverage for 8 consecutive hours on multiple days, and improperly administered pain medication outside of physician orders for one resident. The deficiencies were substantiated with interviews, record reviews, and policy analysis.
Findings
The facility failed to notify the ombudsman of a resident transfer or discharge, did not ensure an RN was on duty for 8 consecutive hours on multiple days, and administered pain medication outside of physician-ordered parameters for one resident, potentially resulting in inadequate pain management and increased fall risk.

Deficiencies (3)
Failure to provide timely notification to the resident, resident representative, and ombudsman before transfer or discharge.
Failure to have a registered nurse on duty for 8 consecutive hours during the day on multiple dates.
Failure to ensure pain medications were administered according to physician's orders, resulting in administration outside prescribed pain parameters.
Report Facts
Medication administration count: 33 Medication administration count: 32

Employees mentioned
NameTitleContext
Staff #66Care Manager Licensed Practical Nurse (LPN)Interviewed regarding resident #70 transfer and discharge notification
Staff #167Care Manager Licensed Practical Nurse (LPN)Interviewed regarding emergency transfer of resident #70
Staff #172Social Services StaffInterviewed regarding awareness of ombudsman notification requirements
Staff #52Certified Nurse Assistant (CNA)Interviewed regarding staffing and resident care
Staff #34Director of NursingInterviewed regarding RN coverage and medication administration
Staff #110Registered NurseInterviewed regarding pain medication administration practices

Inspection Report — Jul 8, 2024

Complaint Investigation State
Date: Jul 8, 2024

Visit Reason
On-site complaint investigation of intakes AZ00212312, AZ00203581, AZ00200491, AZ00198118, and AZ00197277 at a Nursing Care Institution, conducted 8 July 2024.

Complaint Details
An onsite complaint survey was conducted on July 8, 2024 for the investigation of intake #s AZ00212312, AZ00203581, AZ00200491, AZ00198118, AZ00197277. There were no deficiencies cited. Federal comments confirm the same intakes were investigated with no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.

Report Facts
Complaints investigated: 5

Inspection Report — Apr 17, 2024

CMS
Date: Apr 17, 2024

Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing safe and appropriate dialysis care and services, specifically focusing on dialysis assessments and transportation arrangements for residents requiring dialysis.

Findings
The facility failed to ensure dialysis assessments were completed and transportation to dialysis appointments was arranged for one of three sampled residents (#4). The resident missed a scheduled dialysis session on April 10, 2024, resulting in an emergency room visit. Interviews and record reviews confirmed lack of dialysis assessments and transportation scheduling errors.

Deficiencies (2)
Failure to ensure dialysis assessments were completed for resident #4.
Failure to arrange transportation to dialysis appointments for resident #4, resulting in missed dialysis treatment.
Report Facts
Dialysis frequency: 3 Dialysis appointment time: 1130 Dialysis chair time: 230 Missed dialysis dates: 1 Post dialysis assessments documented: 2

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN) staff #90Licensed Practical NurseStated no dialysis assessments were completed for resident #4 and responsible for setting up transportation
Director of Nursing (DON) staff #88Director of NursingConfirmed dialysis assessments were not completed and stated expectations for transportation and assessments
Unit Clerk staff #76Unit ClerkResponsible for scheduling transportation and explained failure to arrange transport for resident #4
Nurse Care Manager staff #65Nurse Care ManagerConducted admission intake and communicated transportation needs for resident #4
Assistant Director of Nursing (ADON) staff #43Assistant Director of NursingProvided information on transportation scheduling and resident's hospital stay

Inspection Report — Apr 17, 2024

Complaint Investigation CMS
Date: Apr 17, 2024

Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure dialysis assessments were completed and transportation to dialysis appointments was arranged for a resident requiring such services.

Complaint Details
The complaint investigation found that the facility did not complete dialysis assessments or arrange transportation for resident #4, resulting in missed dialysis and an emergency room visit. The deficiency was substantiated with evidence from clinical records, staff interviews, and dialysis center documentation.
Findings
The facility failed to complete required pre- and post-dialysis assessments and did not arrange transportation for a resident (#4) to dialysis appointments, resulting in missed dialysis treatment and an emergency room visit. Interviews with staff confirmed lapses in communication and documentation related to dialysis care and transportation.

Deficiencies (2)
Failure to ensure dialysis assessments were completed for resident #4.
Failure to arrange transportation to dialysis appointments for resident #4.
Report Facts
Dialysis frequency: 3 Dialysis appointment time: 1130 Dialysis chair time: 230 Post dialysis assessments documented: 2 Emergency room visit time: 145 Rescheduled dialysis appointment: 500

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN)Interviewed and stated no dialysis assessments were completed for resident #4.
Director of Nursing (DON)Interviewed and confirmed no dialysis assessments were completed and discussed expectations for dialysis care.
Unit ClerkResponsible for scheduling transportation; provided details on transportation lapses for resident #4.
Nurse Care ManagerConducted admission intake and communicated transportation needs for resident #4.
Assistant Director of Nursing (ADON)Interviewed regarding transportation and dialysis scheduling issues for resident #4.

Inspection Report — Jan 31, 2024

Complaint Investigation State
Date: Jan 31, 2024

Visit Reason
On-site complaint investigation of intakes AZ00205760, AZ00205859, and AZ00205835 at a Nursing Care Institution, conducted 31 January 2024.

Complaint Details
The complaint survey was conducted on January 31, 2024 for the investigation of intake numbers AZ00205760, AZ00205859, and AZ00205835. The facility failed to timely report allegations of abuse as required.
Findings
The inspection found two deficiencies related to the facility's failure to timely report an allegation of abuse involving Resident #45 to the State as required by Arizona and federal regulations.

Deficiencies (2)
R9-10-403.E — The facility failed to ensure that an allegation of abuse for Resident #45 was reported to the State within the required time frame despite documented concerns and grievance logs indicating the resident felt abused.
§483.12(c) — The facility failed to report an allegation of abuse for Resident #45 to the administrator and other officials within the required time frames, risking further unreported incidents of abuse.
Report Facts
Deficiencies cited: 2

Inspection Report — Jan 25, 2024

Complaint Investigation State
Date: Jan 25, 2024

Visit Reason
On-site complaint investigation of complaints AZ00205512 and AZ00205307 at a Nursing Care Institution, conducted 25 January 2024.

Complaint Details
The Complaint Survey was conducted January 25, 2024 through January 25, 2024 investigating complaints AZ00205512 and AZ00205307. Federal comments also reference complaints AZ00205510 and AZ00205305. There were no deficiencies cited.
Findings
No deficiencies were found during this complaint investigation.

Report Facts
Complaints investigated: 2

Inspection Report — Nov 29, 2023

Complaint Investigation State
Date: Nov 29, 2023

Visit Reason
On-site complaint investigation of intake AZ00203652 and AZ00203651 at a Nursing Care Institution, conducted 29 November 2023.

Complaint Details
The complaint survey was conducted on November 29, 2023 for the investigation of intake #AZ00203652 and intake #AZ00203651. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.

Inspection Report — Sep 18, 2023

State
Date: Sep 18, 2023

Visit Reason
Inspection of type Other using the Nursing Care Institution worksheet was conducted on 18 September 2023 at SANTE OF MESA.

Findings
This inspection resulted in no citations or deficiency findings.

Inspection Report — Sep 11, 2023

State
Date: Sep 11, 2023

Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 11 September 2023.

Findings
The inspection found one deficiency related to incomplete COVID-19 reporting to the CDC's National Healthcare Safety Network during a required seven-day period.

Deficiencies (1)
§483.80(g) — The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation, potentially causing more than minimal harm to residents.
Report Facts
Deficiencies cited: 1

Inspection Report — Sep 5, 2023

State
Date: Sep 5, 2023

Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 5 September 2023.

Findings
The inspection found one deficiency related to incomplete COVID-19 reporting to the CDC's National Healthcare Safety Network during a required seven-day period.

Deficiencies (1)
§483.80(g) — The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation, potentially causing more than minimal harm to residents.
Report Facts
Deficiencies cited: 1

Inspection Report — Nov 10, 2022

CMS
Date: Nov 10, 2022

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident notification, self-administration of drugs, discharge notification, and food safety in the nursing facility.

Findings
The facility was found deficient in multiple areas including failure to ensure residents and/or their representatives were informed about psychotropic medication risks and benefits, medications left unattended with residents not assessed for self-administration, failure to notify the ombudsman of a resident discharge, administration of medication outside physician-ordered parameters, and improper food storage practices in the kitchen.

Deficiencies (5)
Failure to ensure one resident and/or their representatives were informed in advance of the risks and benefits of proposed treatment with psychotropic medications.
Failure to ensure medications were not left unattended for 4 residents who were not assessed for self-administration of medications.
Failure to notify the ombudsman in writing regarding one resident's discharge.
Failure to ensure medications were administered according to physician ordered parameters for one resident.
Failure to ensure food items in the kitchen dry storage were sealed, dated or not expired.
Report Facts
Sample size: 7 Sample size: 16 Sample size: 2 Sample size: 5 Medication administration occurrences: 12

Employees mentioned
NameTitleContext
Licensed Practical NurseLPN/staff #100Interviewed regarding psychotropic medication consent
Director of NursingDON/staff #171Interviewed regarding psychotropic medication consent, medication self-administration, and medication administration parameters
Licensed Practical NurseLPN/staff #107Interviewed regarding medication administration observation
Registered NurseRN/staff #181Interviewed regarding medication administration observation
Licensed Practical NurseLPN/staff #98Observed and interviewed regarding medication administration and self-administration
Licensed Practical NurseLPN/staff #119Interviewed regarding medication administration and self-administration
Social Services Coordinatorstaff #155Interviewed regarding ombudsman notification
Administratorstaff #182Interviewed regarding ombudsman notification
Licensed Practical NurseLPN/staff #128Interviewed regarding medication administration parameters
Dietary Managerstaff #139Interviewed regarding food storage and labeling

Inspection Report — Nov 10, 2022

Routine CMS
Date: Nov 10, 2022

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, discharge notification, and food safety at the nursing facility.

Findings
The facility was found deficient in several areas including failure to ensure residents and/or their representatives were informed about psychotropic medication risks, medications left unattended without proper assessment for self-administration, failure to notify the ombudsman of a resident discharge, administration of medication outside physician ordered parameters, and improper food storage practices in the kitchen.

Deficiencies (5)
Failure to ensure residents were fully informed and understood their health status, care, and treatments related to psychotropic medication consent.
Failure to ensure medications were not left unattended for residents who were not assessed for self-administration of medications.
Failure to provide timely notification to the ombudsman regarding a resident's discharge.
Failure to administer medications according to physician ordered parameters for one resident.
Failure to ensure food items in the kitchen dry storage were sealed, dated, or not expired.
Report Facts
Sample size: 7 Sample size: 16 Sample size: 2 Sample size: 5 Number of occasions: 12

Employees mentioned
NameTitleContext
Licensed Practical NurseInterviewed regarding psychotropic medication consent and medication administration
Director of NursingInterviewed regarding psychotropic medication consent, medication administration, and self-administration policies
Social Services CoordinatorInterviewed regarding ombudsman notification for resident discharge
AdministratorInterviewed regarding ombudsman notification policy
Licensed Practical NurseInterviewed regarding medication administration parameters
Dietary ManagerInterviewed regarding food storage and labeling practices
Culinary Services DirectorInterviewed regarding food storage and labeling practices

Inspection Report — Oct 8, 2021

Routine CMS
Date: Oct 8, 2021

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, abuse and neglect prevention, infection control, and other facility policies.

Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with uncovered catheter bags, inconsistent advance directive documentation, improper medication administration resulting in resident death, failure to timely report neglect, improper pain medication administration, inconsistent bathing, unnecessary medication use, and lapses in infection control practices.

Deficiencies (8)
Failure to ensure one resident's urinary catheter bag was covered, compromising dignity and privacy.
Failure to ensure one resident's code status was consistent in the clinical record.
Failure to prevent neglect resulting in administration of oral medications through an intravenous line causing resident death.
Failure to timely report suspected neglect to the State Agency and Adult Protective Services within required timeframe.
Failure to administer pain medications according to physician orders.
Failure to provide consistent showers/bathing to one resident.
Failure to ensure two residents were free from unnecessary medication.
Failure to ensure proper hand hygiene between glove use and urinary catheter bag placement off the floor.
Report Facts
Deficiencies cited: 8 Medication doses: 10 Medication doses: 5

Employees mentioned
NameTitleContext
Staff #179Certified Nursing AssistantMentioned in catheter bag coverage deficiency and infection control observation
Staff #159Registered NurseMentioned in catheter bag coverage deficiency and infection control observation
Staff #182Registered NurseInvolved in medication error leading to resident death
Staff #7Director of NursingInterviewed regarding multiple deficiencies including medication administration and reporting
Staff #126Registered NurseInterviewed regarding advance directive process
Staff #176Charge NurseInvolved in code blue response and investigation
Staff #180AdministratorInterviewed regarding incident reporting and investigation
Staff #62Assistant Director of NursingInterviewed regarding medication administration and bathing policies
Staff #37Registered NurseInterviewed regarding pain medication administration
Staff #174Certified Nursing AssistantObserved and interviewed regarding catheter care and infection control
Staff #124Certified Nursing AssistantInterviewed regarding bathing documentation
Staff #102Licensed Nursing AssistantInterviewed regarding risks of inconsistent showers
Staff #212Registered PharmacistInterviewed regarding medication administration through PICC line
Staff #232Medical DirectorInterviewed regarding medication administration through PICC line

Inspection Report — Oct 8, 2021

Complaint Investigation CMS
Date: Oct 8, 2021

Visit Reason
The inspection was conducted based on complaints and allegations regarding resident care, medication administration errors, neglect, and infection control issues at the facility.

Complaint Details
The investigation was triggered by complaints regarding neglect and improper medication administration, including a fatal medication error where oral medications were administered through a PICC line, resulting in resident #318's death. The facility failed to report the neglect timely to the State Agency and Adult Protective Services.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with catheter care, inconsistent advance directive documentation, medication administration errors resulting in resident death, failure to timely report neglect, improper pain medication administration, inconsistent bathing care, unnecessary medication use, and lapses in infection prevention and control practices.

Deficiencies (8)
Failure to ensure resident's urinary catheter bag was covered, compromising dignity and privacy.
Failure to ensure consistent and accurate advance directive documentation for resident code status.
Failure to prevent neglect resulting in administration of oral medications through a PICC line causing resident death.
Failure to timely report suspected neglect to State Agency and Adult Protective Services within required timeframe.
Failure to administer pain medications according to physician orders and pain scale parameters.
Failure to provide consistent showers/bathing to resident, resulting in poor hygiene and dry skin.
Failure to ensure residents were free from unnecessary medications.
Failure to practice proper hand hygiene between glove use and failure to keep urinary catheter bag off the floor.
Report Facts
Deficiencies cited: 8 Medication administration times: 10

Employees mentioned
NameTitleContext
Staff #179Certified Nursing AssistantObserved catheter bag uncovered and stated intention to cover it; provided catheter care
Staff #159Registered NurseInterviewed regarding catheter bag policy and hand hygiene; observed catheter care
Staff #182Registered NurseAdministered oral medications through PICC line resulting in resident death; suspended and terminated
Staff #7Director of NursingInterviewed about advance directives, medication error, and reporting procedures
Staff #180AdministratorInterviewed regarding incident reporting and family notification
Staff #126Registered NurseInterviewed about advance directive procedures
Staff #37Registered NurseInterviewed about pain medication administration
Staff #62Assistant Director of NursingInterviewed about medication administration and bathing policies
Staff #174Certified Nursing AssistantObserved providing catheter care and interviewed about hand hygiene
Staff #124Certified Nursing AssistantInterviewed about bathing documentation practices
Staff #102Licensed Nursing AssistantInterviewed about risks of inconsistent showers
Staff #212Registered PharmacistInterviewed about dangers of administering oral meds through PICC line

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