Phoenix Center for Rehabilitation and Nursing,the

Inspectors wroteBased on review of facility policy, observations, review of facility documentation and staff interviews, it was determined the facility failed to ensure hot water temperatures in residents' room and shower rooms were maintained at a safe temperature on one of three nursing units (Third floor). This failure placed the residents at risk of serious injury from a burn and resulted in an Immediate Jeopardy Situation.

Inspectors wroteBased on observations, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to hot water temperatures which resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to provide a clean environment for 15 of twenty-three residents located on the 3rd floor care unit. (Resident 1's, Resident 2's, Resident 3's, Resident 4's, Resident 5's, Resident 6's, Resident 7's, Resident 8's, Resident 9's, Resident 10's, Resident 11's. Resident 12's, Resident 13's, Resident 14's, and Resident 15's rooms)Findings Include:Observations made on April 22, 2026, between 10 a.m. and 12 p.m., of resident rooms on the 3rd floor care unit revealed Resident 1, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11. Resident 12, Resident 13, Resident 14, and Resident 15 had window curtains that were soiled or had brown stains on them. Observations on April 22, 2026 at 10 a.m. [...]

Inspectors wroteBased on observation, a review of clinical records, and interviews with residents and staff, it was determined that the facility failed to provide a homelike environment for one of the three residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for five of ten residents reviewed for hospitalization (Resident 1, Resident 3, Resident 31, Resident 86 and Resident 88). Review of Resident 1's clinical record revealed a face sheet documenting the resident has medical diagnoses that include Acute Respiratory Failure with Hypoxia (insufficient oxygen in blood). Review of Resident 1's clinical record revealed that they were transferred and admitted to the hospital on [DATE], due to respiratory distress. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on a review of closed clinical records, facility policy review, and staff interview, it was determined that the facility failed to assure a Residents right to be free of chemical restraints for one of one Residents reviewed. (Resident 6).

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined that the facility failed to properly follow physician orders for three of 19 residents reviewed and failed to timely address a skin issue for one of 19 residents reviewed(Resident 1, Resident 5, Resident 30 and Resident 35). Review of Resident 1's face sheet revealed medical diagnoses that include Acute Respiratory Failure with Hypoxia (insufficient oxygen in blood). Review of Resident 1's clinical records revealed physician orders for oxygen continuous at 2 liters via nasal cannula every shift for monitor. Review of resident 1's clinical records revealed physician orders to change oxygen tubing, mask and/or nasal cannula weekly on Wednesday 11p.m. to 7 a.m. shift, date tubing and H20 bottle, wash filter, may change sooner as needed, every night shift every Wednesday for hygiene. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on clinical record review, and staff interview, it was determined the facility failed to provide a hazard free environment for one of eight residents reviewed (Resident 6).

Inspectors wroteBased on review of facility policy, facility documentation, observations, and staff interviews, it was determined the facility failed to ensure hot water temperatures in residents' room and shower rooms were maintained at a safe temperature on three of three nursing units (First, Second and Third floors). This failure placed the residents at risk of serious injury from a burn and resulted in an Immediate Jeopardy Situation. Findings Include: Review of facility policy and procedure titled Test and Log the Hot Water Temperatures, undated, stated for burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temp can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120 degrees Fahrenheit is considered a safe water temperature for bathing. [...]

Inspectors wroteBased on observations, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator failed to effectively manage the facility related to hot water temperatures which resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautionswere in place for residents requiring enhanced barrier precautions for two of three residents reviewed (Resident 2, and Resident 3).

Inspectors wroteBased on observations, resident interviews and staff interview it was determined the facility failed to ensure a comfortable environment with temperatures below 71 degrees for one room. (Resident 1's room) Findings Include: Observations of Resident 1's room on February 20, 2025 at 9:15 a.m. revealed the resident laying in bed fully clothed with a blanket over them. Interview with Resdient 1 on February 20, 2025 at 9:15 a.m. revealed the heating unit for the room was not working. When it is turned on it will smoke and there is a smell of burning plastic and he was cold. Air temperature of the room recorded by the Nursing Home Administrator using an infrared thermometer gun on February 20, 2025 at 11:15 a.m. recorded a temperature of 68 degrees Fahrenheit. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to immediately notify the resident's representative of an accident involving the resident which resulted in an injury for one of three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policies, investigation reports, and clinical records, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 8 residents reviewed (Resident 1)

Inspectors wroteBased upon review of facility policy and procedure, observation, and clinical record review, it was determined the facility failed to establish Enhanced Barrier Precautions for four of four residents observed (Resident 16, Resident 54, Resident 58, and Resident 173).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview it was determined the facility failed to monitor the nutritional status for three of seven residents reviewed. (Residents 4, 15, and 66) Findings Include: Review of facility policy Weight Assessment and Intervention updated January 10, 2023, revealed weights will be recorded in each unit's Weight Record chart or notebook and then entered in the individual's medical record by the facility's designated weight manager. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. Review of Resident 4's weights revealed a weight on July 18, 2024, of 154.4 pounds and a weight on August 1, 2024 of 170.2 ( gain of 15.8 pounds or 9.3%). [...]

Inspectors wroteBased upon clinical record review and interview, it was determined the facility failed to ensure the formulation of Advance Directives was offered upon admission for one of 18 residents reviewed (Resident 223).

Inspectors wroteBased on facility policy and procedure review, clinical record review, and staff interview, it was determined the facility failed to notify the physician of a change in a resident condition for one of 24 residents reviewed. (Resident 173) Findings Include: Review of facility policy and procedure titled Change in a Residents Condition or Status, Revised December 2016, revealed Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medica;/mental condition and/or status. The nurse will notify the resident's Attending Physician or physician on call when there has been a(n): significant change in the resident's physical/emotional/mental condition. Review of Resident 173's progress notes reveled a nursing entry dated December 9, 2023 at 6:50 a.m. stating Resident was received in bed. [...]

Inspectors wroteBased upon review of facility policy and procedure, clinical records, and documentation provided by the facility and staff interviews, it was determined the facility failed to thoroughly investigate a fall causing possible injury for one of 18 residents reviewed (Resident 223).

Inspectors wroteBased on clinical record review, hospital record review, and staff interview it was determined the facility failed to provide care and services related to monitoring a residents health status and following recommendations after transfer from an acute care hospital for one of 24 residents reviewed. (Resident 173) Findings Include: Review of facility policy and procedure titled Acute Condition Changes- Clinical Protocol, last revised December 2015 revealed before contacting a physician about someone with an acute change in condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician .nurses are encouraged to use the communication form and progress note as a tool to help gather and organize information before notifying the physician. [...]

Inspectors wroteBased on observation, clinical record review and staff interview it was determined the facility failed to provide care and services for a resident with a foley catheter for one of two residents reviewed. (Resident 54) Findings Include: Observation of Resident 54 on August 19, 2024 at 9:30 a.m. revealed the resident had a Foley catheter (Tube placed into the bladder to drain urine). Review of Resident 54 clincal record revealed the resident was admitted to the facility on [DATE] with a Foley catheter. Further review of Resident 54's clinical record revealed there was no assessment to determine the need of the foley catheter and the catheter was not removed to attempt a voiding trial after admission. Review of Resident 54's progress notes revealed a nursing entry dated August 21, 2024 at 4:11 p.m. [...]

Inspectors wroteBased upon observation and clinical record review, it was determined the facility failed to ensure tube feedings were delivered according to physician orders for one of three residents observed (Resident 16).

Inspectors wroteBased on clinical records hospital records review and staff interviews it was determined that the facility failed to provide respiratory treatment and services timely for one of the two residents reviewed (Resident CL1).

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment for one of three nursing units (Third floor nursing unit).

Inspectors wroteBased on clinical records review, and resident and staff interviews, it was determined that the facility failed to ensure physician's orders were followed for four of 19 residents reviewed (Resident 31, 51, 59, and 67).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to update care plans to accurately reflect the resident's current status for 2 of 24 residents reviewed. (Residents 29 and 37) Findings Include: Review of resident 29's Diagnosis list included diagnosis for depression and dementia. Review of Resident 29's physician orders revealed an order for Buspar (anti-anxiety medications) 10 milligrams, three times a day for anxiety. Review of Resident 29's care plan revealed a care plan for the resident being on an antidepressant medication. Review of resident 29's physician orders revealed the resident was not on any antidepression medications. [...]

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to appropriately monitor and assess pressure ulcers for one of the four residents reviewed (Resident 51).

Inspectors wroteBased on a review of the facility's policy, clinical records review, and resident and staff interviews, it was determined that the facility failed to ensure appropriate supervision was provided during smoking for one of three residents reviewed (Resident 60)

Inspectors wroteBased on clinical record review, facility policy review, and staff interview it was determined the facility failed to monitor the nutritional status of one of 3 residents reviewed. (Resident 37) Findings Include: Review of facility policy Weight Assessment and Intervention, revised September 2008, revealed weights should be completed at least monthly. Review of Resident 37's weights revealed there was no weight completed for the month of August 2023. Further review of Resident 37's weights revealed a weight on September 6, 2023 of 218 pounds, a decrease of 8.6 pounds from the previous weight obtained on July 4, 2023 of 225.6 pounds. Review of resident 37's progress notes revealed this weight loss was addressed by the dietitian on July 14, 2023 by requesting staff to obtain another weight for accuracy. [...]

Inspectors wroteBased on observation, clinical records review, and staff interview, it was determined that the facility failed to correctly administer medications for one of four residents observed in accordance with a physician orders, resulting in a medication error rate of 13.79% percent (Resident 69).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to maintain records accurately reflecting the resident's status for one of 24 residents reviewed. (Resident 29) Findings Include: Review of Resident 29's progress notes revealed a nursing entry dated [DATE] stating CNA (Certified Nursing Assistant) came to this nurse to make aware of open area noted while giving care. Observed an open area to resident right hip measuring 1cm (centimeters) by 0.5cm. Review of Resident 29's physician orders revealed an order dated [DATE] to cleanse right hip with NSS (Normal Saline Solution-sterile salt water), apply triple antibiotic ointment, cover with clean dry dressing. one time a day for open area for 10 Days or until area resolved. [...]

Inspectors wroteBased upon clinical record review and staff interview, it was determined the facility failed to notify the State Ombudsman's office of hospitalization of a resident for four of four residents reviewed (Residents 21, 25, 34, and 69).