Phoenix Mountain Post Acute

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that menus provided alternate meal options for residents who refused the food offered. The census was 110, and the sample size was 22. The deficient practice had the potential to affect all residents in the facility by limiting resident choice and failing to meet individual nutritional preferences and needs.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure that proper infection control practices were implemented according to professional standards for five residents (#6,11, 25, 67 and 99). This deficient practice could lead to the spread of infection. Based on observation, clinical record review, interviews and a review of policies and procedures, the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for four residents (#99, #6, #25, and #11). This deficient practice could result in an increased risk of pathogen transmission.

Inspectors wroteNumber of residents sampled: 110Number of residents cited: 1Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure that individualized activities were consistently offered to one resident (#9). The facility census consisted of 110 residents, and the target sample size was 22. The deficient practice could result in residents not consistently being provided with activities that meet their interests and support their physical, mental, and psychosocial well-being.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure medications were administered within ordered parameters and according to accepted standards of practice for 1 of 5 residents reviewed for unnecessary medications (Resident #6). The census was 110, and the sample size was 22. The deficient practice had the potential to cause adverse drug effects and place residents at risk for harm from unnecessary medications that were not clinically indicated at the time of administration.

Inspectors wroteBased on clinical record review, facility documentation, staff interview, and policy review, the facility failed to ensure the Narcotic Log/count Q shift Monitoring sheet was accurately completed. The deficient practice could result in narcotics not being accounted for. During an observation conducted on September 17, 2025, at 9:58 AM of the medication cart 200 even numbered room, with License Practical Nurse (LPN/Staff #39) stated that the Narcotic Log/Count Q shift Monitoring was incomplete for the following days in September 2025: 10, 11, 13, 14, 15. She further stated that there was no day shift nurse signature for September 10th and 11th of 2025. [...]

Inspectors wroteBased on interviews, facility documentation and policy, the facility failed to ensure patient care equipment was maintained according to manufactures recommendations and kept in safe operating condition. The deficient practice could result in a resident not receiving basic life support with an Automated External Defibrillator (AED). Findings Include: An observation was conducted with the Executive Director (Staff # 07) on May 28, 2025 at 12:00 p.m. of the facility's Core Crash Cart. The defibrillator is stored in the bottom drawer of the Core Crash Cart with a blinking green light. The crash cart daily checkoff list is located on top of the cart. According to an invoice dated December 20, 2021, the facility acquired the AED machine. According to the user manual, version DAC-A580-EN-DL, the Operator's Checklist should be used as a basis for routine maintenance. [...]

Inspectors wroteBased on clinical record review, observations, interviews, facility documentation and policy, the facility failed to ensure that one resident (#435) with an intellectual disability was properly groomed, and provided proper hygiene. The sample size was three residents. The deficient practice could result in the resident being ostracized and ridiculed at the facility, adversely impacting self esteem.

Inspectors wroteBased on review of the facility assessment, facility documentation, staff interviews, personnel files, and facility policy, the facility failed to ensure that one staff member (#65) had the competencies and skill sets necessary to provide nursing and related services to safely meet one resident's (#166) transfer needs. The deficient practice regarding resident transfer equipment could increase the risk for accident-related injuries.

Inspectors wroteBased on review of the clinical record, staff interviews, and review of policies and procedures, the facility failed to ensure clinical record documentation was accurately documented for one resident (#111) regarding medication administration. The deficient practice has the potential for clinical records to inaccurately and incompletely reflect the administration of medications to all residents.

Inspectors wroteBased on resident, resident representative, and staff interviews and facility documentation, the facility failed to protect the resident's (#11) right to be free from sexual abuse by a staff. The deficient practice could result in residents' increase risk of further harm and abuse.

Inspectors wroteBased on observations, resident and staff interviews, and facility policy and procedures, the facility failed to ensure that walls were painted in 4 (#64, #154, #40, and #63) residents' rooms and blinds were not broken in two residents' (#64 and #154) rooms. The census was 104. The deficient practice may result in the facility not maintaining a safe/clean, comfortable and homelike environment.

Inspectors wroteBased on documentation, staff interviews, and facility policy and procedures, the facility failed to notify two residents in writing (#10 and #24) of the reason for transfers. The sample size was 27. The deficient practice may result in residents and/or their representatives not being notified of the rationale for resident transfers.

Inspectors wroteBased on documentation, staff interviews, and facility policy and procedures, the facility failed to provide two residents (#10 and #2) with the bed-hold policy prior to being transferred to the hospital. The sample size was 27. The deficient practice may result in residents and/or their representatives not being informed of the bed-hold policy.

Inspectors wroteBased on observations, staff interviews, clinical record review and policy, the facility failed to ensure two residents (#23, #79) received catheter care and services in accordance with professional standards of practice. The sample size was 2. The deficient practice may increase the risk for urinary tract infections (UTI).

Inspectors wroteBased on clinical record review, resident and staff interviews, facility records, and the facility assessment, the facility failed to ensure that there was sufficient nursing staff to meet the needs of residents 6 residents (#8, #72, #49, #52, #94, and #64). The census was 104. The deficient practice could result in resident's care needs not being met.

Inspectors wroteBased on observations, facility documentation, staff interviews, policy review, and the glucose control solution instructions, the facility failed to ensure that 2 bottles of glucometer control solutions were dated when opened on 2 out of 3 medication carts observed. The sample size was 27. The deficient practice could result in inaccurate blood glucose test results.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that dishes and utensils were cleaned under sanitary conditions and that spoiled and/or unpalatable refrigerated and frozen foods were available to be served to residents. The census was 104. The deficient practice could result in residents becoming ill.

Inspectors wroteBased on observation, clinical record review, interviews and policy review, the facility failed to ensure an alternate food choice during meals was provided to one out of two residents reviewed (#12). The deficient practice could result in not honoring the choices that are significant to the resident.

Inspectors wroteBased on clinical review, staff interviews, and facility policy and procedures, the facility failed to monitor and administer one resident's (#97) medications as prescribed in accordance with professional standards of practice. The sample size was 5. The deficient practice could result in residents' medical conditions not being effectively managed.

Inspectors wroteBased on observation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure hazardous chemicals were stored safely for one resident (#64). The census was 104. The deficient practice could result in residents being harmed by unsecured chemicals.

Inspectors wroteBased on facility documentation, staff interviews and policy review, the facility failed to ensure that current nurse staffing information was accurate for actual hours worked and actual staffing totals worked by licensed and unlicensed direct care nursing staff for 6 out of 7 days reviewed. The census was 104. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one (#97) resident did not receive pain medication outside of the physician's ordered parameters. The sample size was 5. The deficient practice could result in residents receiving unnecessary medications.

Inspectors wroteBased on observation, staff interviews, and policy and procedures, the facility failed to ensure that refuse was disposed of appropriately. The deficient practice could result in an unsanitary condition and the harborage of pests and insects.

Inspectors wroteBased on observation, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control during catheter care for one resident (#23). The sample size was 2. The deficient practice could result in transmission of infection, or exposing the resident to other organisms.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure dialysis services were consistent with professional standards of practice for one of one sampled residents (#44). The deficient practice could result in dialysis related complications not being readily identified and treated timely.

Inspectors wroteBased on review of facility and clinical records, staff interviews, observation, and review of policy and procedure, the facility failed to provide a care planned and ordered assistive device to one resident (#53) related to a history of falls. The sample size was four residents. The deficient practice could result in increased resident injuries.

Inspectors wroteBased on observations, resident and staff interviews, facility documentation, and facility policy and procedure, the facility failed to ensure that the oxygen tubing was changed for one of one sampled residents (#37). The deficient practice could result in respiratory complications.