Inspection Reports for
Phoenix Mountain Post-Acute

The complaint was an anonymous report submitted to the Bureau of Long-term Care on June 17, 2025, alleging that Resident #435 was allowed to walk around the facility and dining area with briefs always soaked. The complaint was substantiated by observations and interviews during the inspection.

The facility failed to ensure proper grooming and hygiene for Resident #435, who was observed in a disheveled, malodorous state with stained clothing and skin flaking. Additionally, the facility failed to maintain an Automated External Defibrillator (AED) in safe operating condition, with documentation showing malfunction and lack of routine checks.

The facility failed to ensure that a staff member had the necessary competencies to safely use a Hoyer lift for resident transfers without assistance, and failed to maintain accurate clinical record documentation for medication administration for one resident, potentially risking resident safety and care accuracy.

The complaint investigation focused on staff competency in using mechanical lifts safely and the accuracy of medication administration documentation. The findings were substantiated with observations and multiple staff interviews confirming policy violations and documentation inaccuracies.

The facility failed to ensure that a staff member had the necessary competencies to safely use a Hoyer lift for resident transfers, violating facility policy requiring two staff members for such transfers. Additionally, the facility failed to maintain accurate clinical record documentation for medication administration, specifically for one resident's Clozapine medication, leading to inaccurate medication records.

The complaint investigation was substantiated with findings that Resident #11 was sexually abused by Staff #20. The resident reported the relationship and abuse to facility leadership and family. The staff member denied sexual contact but admitted to exchanging phone numbers and texting. The facility concluded the relationship was inappropriate and unprofessional but did not meet the state's definition of abuse. The resident's family reported ongoing emotional distress and alleged attempts to cover up the incident by facility staff.

The facility failed to protect Resident #11 from sexual abuse by Staff #20, who engaged in an inappropriate and unprofessional relationship involving oral sex on two occasions. Multiple interviews with the resident, staff, and facility leadership revealed inconsistent accounts, with the resident providing evidence of text messages and the staff member denying sexual contact. The facility concluded the relationship was inappropriate but did not classify it as abuse under state statute. The resident experienced emotional distress, and the staff member was terminated. The facility reported the staff member to the State Board of Nursing and reviewed policies on professional boundaries and abuse prevention.

The facility was found deficient in multiple areas including failure to honor resident food choices, maintain a safe and homelike environment, timely notify residents of transfers and bed-hold policies, monitor and administer medications properly, provide adequate catheter care, maintain sufficient nursing staff, ensure accurate nurse staffing postings, prevent unnecessary drug administration, maintain proper laboratory and food safety practices, dispose of refuse properly, and implement infection prevention and control during catheter care.

The facility was found deficient in providing a care planned and ordered assistive device to a resident at high risk for falls, ensuring oxygen tubing was changed for a resident receiving oxygen therapy, and ensuring dialysis services were consistent with professional standards including proper documentation and monitoring of dialysis access and treatments.

The investigation was complaint-driven, focusing on allegations of inadequate fall prevention measures, oxygen therapy management, and dialysis care. The report documents substantiated deficiencies in these areas.

The facility was found deficient in providing a care planned assistive device (fall mats) for a high-risk resident, failing to change oxygen tubing for a resident on oxygen therapy, and not ensuring consistent dialysis care documentation and monitoring for a resident receiving dialysis.

The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments for several residents, incomplete baseline care plans, failure to monitor vital signs during a resident's change of condition, inadequate pressure ulcer assessment, insufficient hydration and nutrition management leading to hospitalization, and medication storage issues including expired medications and unlocked medication carts.

The complaint investigation focused on multiple deficiencies including inaccurate MDS assessments, inadequate care planning, failure to monitor vital signs, inadequate pressure ulcer care, dehydration and nutrition issues leading to hospitalization, and medication storage violations.

The facility failed to ensure accurate MDS assessments for multiple residents, failed to develop adequate baseline care plans, failed to monitor vital signs during a resident's change of condition, failed to maintain adequate hydration leading to hospitalization, failed to thoroughly assess and document pressure ulcers, and failed to properly secure medication carts and remove expired medications.