Inspection Reports for
Phoenix Mountain Post-Acute
13232 N Tatum Blvd, Phoenix, AZ 85032, United States, AZ, 85032
Back to Facility Profile36 Reports
Inspection Report — Dec 4, 2025
Annual Inspection
Date: Dec 4, 2025
Visit Reason
On-site complaint and annual compliance inspection at a Nursing Care Institution conducted 4 December 2025.
Complaint Details
An offsite follow up survey was conducted on December 04, 2025. There were no deficiencies cited.
Findings
This inspection found no deficiencies; all required plans of correction were provided and accepted.
Deficiencies (9)
§483.24(c) — No evidence of noncompliance was provided regarding the facility's activities program supporting residents' physical, mental, and psychosocial well-being.
§483.45(d) — No evidence of noncompliance was provided regarding the requirement that each resident's drug regimen be free from unnecessary drugs.
§483.50(a) — No evidence of noncompliance was provided regarding the provision or obtaining of laboratory services to meet residents' needs.
§483.60(c) — No evidence of noncompliance was provided regarding menus meeting nutritional needs and reflecting residents' cultural and dietary preferences.
§483.80 — No evidence of noncompliance was provided regarding the establishment and maintenance of an infection prevention and control program.
R9-10-412 — No evidence of noncompliance was provided regarding the director of nursing ensuring that unnecessary drugs are not administered to residents.
R9-10-421 — No evidence of noncompliance was provided regarding policies and procedures for storing, inventorying, and dispensing controlled substances.
R9-10-422 — No evidence of noncompliance was provided regarding policies and procedures covering the use of personal protective equipment.
R9-10-423 — No evidence of noncompliance was provided regarding providing food substitutions of similar nutritional value when residents refuse the food served.
Report Facts
Deficiencies cited: 9
Inspection Report — Dec 4, 2025
Date: Dec 4, 2025
Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 4 December 2025.
Findings
Two deficiencies were found during this inspection. One deficiency lacked evidence and plan of correction, while the other involved failure to install a remote stop or kill switch for the emergency generator.
Deficiencies (2)
Sprinkler System - Maintenance and Testing — No evidence was provided regarding the inspection, testing, and maintenance of the automatic sprinkler and standpipe systems.
Electrical Systems - Essential Electric System Maintenance and Testing — The facility failed to ensure that a remote stop or kill switch for the generator was installed, which could result in loss of power or fire hazards affecting residents and staff.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 19, 2025
Annual Inspection
Date: Nov 19, 2025
Visit Reason
On-site complaint and annual recertification inspection conducted from September 16 through November 19, 2025, investigating complaints 2617425, 2617952, 2619172, 2619078, 2620430, and 2621428 at a Nursing Care Institution.
Complaint Details
The onsite recertification and complaint survey was conducted from September 16 through September 19, 2025, investigating complaints 2617425, 2617952, 2619172, 2619078, 2620430, and 2621428.
Findings
The inspection found nine deficiencies related to individualized activities, medication administration, narcotic log accuracy, menu options, infection control practices, and policies for medication and protective equipment. Plans of correction were provided for all deficiencies.
Deficiencies (9)
§483.24(c) — The facility failed to ensure that individualized activities were consistently offered to one resident, potentially affecting residents' physical, mental, and psychosocial well-being.
§483.45(d) — The facility failed to ensure medications were administered within ordered parameters and accepted standards for one of five residents reviewed for unnecessary medications, risking adverse drug effects.
§483.50(a) — The facility failed to ensure the Narcotic Log/count Q shift Monitoring sheet was accurately completed, risking narcotics not being accounted for.
§483.60(c) — The facility failed to ensure menus provided alternate meal options for residents who refused the food offered, limiting resident choice and nutritional preferences.
§483.80 Infection Control — The facility failed to ensure proper infection control practices were implemented according to professional standards for five residents, risking spread of infection.
R9-10-412 — The facility failed to ensure medications were administered within ordered parameters and accepted standards for one of five residents reviewed for unnecessary medications, risking harm from unnecessary drugs.
R9-10-421 — The facility failed to ensure policies and procedures were established and implemented to protect resident health and safety in storing, inventorying, and dispensing controlled substances.
R9-10-422 — The facility failed to ensure policies and procedures were established and implemented covering the use of personal protective equipment when applicable, risking infection spread.
R9-10-423 — The facility failed to ensure that menus provided food substitutions of similar nutritional value for residents who refused the food served, limiting resident choice and nutritional needs.
Report Facts
Deficiencies cited: 9
Complaints investigated: 6
Inspection Report — Sep 24, 2025
Complaint Investigation
Date: Sep 24, 2025
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On-site complaint investigation of complaints 00145712 and 2624784 at a Nursing Care Institution, conducted 24 September 2025.
Complaint Details
The investigation of complaints 00145712 and 2624784 was conducted on September 24, 2025. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 7, 2025
Complaint Investigation
Date: Aug 7, 2025
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On-site complaint investigation of complaint 2574816 at a Nursing Care Institution, conducted 7 August 2025.
Complaint Details
The onsite complaint survey was conducted on and investigated August 7, 2025 and investigated complaint # 2574816. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 1
Inspection Report — Jul 11, 2025
Complaint Investigation
Date: Jul 11, 2025
Visit Reason
The inspection was conducted in response to an anonymous complaint alleging that a resident (#435) with an intellectual disability was not properly groomed and was allowed to walk around the facility with soiled briefs, raising concerns about hygiene and dignity.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure Resident #435 was properly groomed and provided proper hygiene, resulting in potential harm to dignity and self-esteem.
Failure to maintain patient care equipment, specifically the AED, according to manufacturer recommendations, risking resident safety.
Report Facts
Resident sample size: 3
Dates of shower refusals: Repeated refusals of baths/showers from April 2025 to July 11, 2025
Date of complaint: June 17, 2025
Date of survey completion: July 11, 2025
BIMS score: 15
Dates of AED malfunction and maintenance: AED malfunction noted May 11, 2025; battery replacement instructions May 15, 2024; manufacturer contacted May 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Observed resident #435 in disheveled state and discussed resident's resistance to care |
| Director of Nursing | DON | Participated in exit conference acknowledging resident's resistance to care and facility's efforts |
| Executive Director | ED | Participated in panel discussion regarding AED maintenance and policies |
Inspection Report — Jun 17, 2025
Routine
Date: Jun 17, 2025
Visit Reason
The inspection was conducted to assess compliance with nursing and clinical care standards, including staff competencies in resident transfers and accuracy of clinical record documentation regarding medication administration.
Findings
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.
Deficiencies (2)
Failure to ensure one staff member had competencies and skill sets necessary to safely use a Hoyer lift for resident transfers without a second staff member present.
Failure to ensure clinical record documentation was accurately documented for one resident regarding medication administration, leading to potential inaccuracies in clinical records.
Report Facts
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #65 | Certified Nursing Assistant | Named in finding regarding improper use of Hoyer lift without second staff member |
| Staff #12 | Licensed Practical Nurse | Interviewed regarding medication administration process and documentation |
| Staff #17 | Certified Nursing Assistant | Interviewed regarding facility expectations for Hoyer lift usage |
| Staff #81 | Director of Nursing | Interviewed regarding facility policy and expectations for Hoyer lift usage and medication documentation |
| Staff #94 | Licensed Practical Nurse | Interviewed regarding Hoyer lift usage policy |
| Staff #11 | Licensed Practical Nurse | Interviewed regarding medication availability and documentation |
| Staff #159 | Contracted Psychiatric Provider | Interviewed regarding medication delays and documentation expectations |
Inspection Report — Jun 17, 2025
Complaint Investigation
Date: Jun 17, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding staff competencies in safely transferring residents using mechanical lifts and the accuracy of clinical record documentation related to medication administration.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure staff member had competencies and skill sets necessary to safely use Hoyer lift for resident transfer without a second staff member present.
Failure to ensure clinical record documentation was accurately documented for medication administration of Clozapine for one resident.
Report Facts
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #65 | Certified Nursing Assistant | Named in deficiency regarding improper use of Hoyer lift without second staff member |
| Staff #17 | Certified Nursing Assistant | Interviewed regarding Hoyer lift usage and facility expectations |
| Staff #94 | Licensed Practical Nurse | Interviewed regarding Hoyer lift usage policy |
| Staff #81 | Director of Nursing | Interviewed regarding facility policy and expectations for Hoyer lift usage and medication documentation |
| Staff #12 | Licensed Practical Nurse | Interviewed regarding medication administration process and documentation |
| Staff #11 | Licensed Practical Nurse | Interviewed regarding medication availability and documentation |
| Staff #159 | Contracted Psychiatric Provider | Interviewed regarding medication delays and documentation expectations |
Inspection Report — May 14, 2025
Complaint Investigation
Date: May 14, 2025
Visit Reason
On-site complaint investigation of multiple complaints including AZ00171204, AZ00180766, AZ00172323, AZ00169260, AZ00182014, AZ00163259, AZ00164082, AZ00164136, AZ00175850, AZ00183459, AZ00177340, AZ00178738, AZ00179567, and AZ00181412 at a Nursing Care Institution, conducted 13-14 May 2025.
Complaint Details
The Risk Based Complaint Survey was conducted May 13, 2025 through May 14, 2025 for the investigation of the following intake #s: AZ00171204, AZ00180766, AZ00172323, AZ00169260, AZ00182014, AZ00163259, AZ00164082, AZ00164136, AZ00175850, AZ00183459, AZ00177340, AZ00178738, AZ00179567, AZ00181412.
Findings
Two deficiencies were cited during this complaint investigation. No evidence text was provided for either deficiency.
Deficiencies (2)
R9-10-403 — No evidence was provided regarding the administrator's failure to ensure policies and procedures protect resident rights, including assistance for residents who do not speak English or have disabilities.
R9-10-410 — No evidence was provided regarding the administrator's failure to ensure residents are not subjected to abuse.
Report Facts
Deficiencies cited: 2
Inspection Report — May 7, 2025
Complaint Investigation
Date: May 7, 2025
Visit Reason
On-site complaint investigation of complaints AZ00173619, AZ00173618, AZ00167612, AZ00224366, and AZ00224454 at a Nursing Care Institution, conducted 7 May 2025.
Complaint Details
The complaint survey was conducted on May 7, 2025 for the following complaint #'s AZ00173619, AZ00173618, AZ00167612, AZ00224366, AZ00224454. There were no deficiencies cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Mar 31, 2025
Complaint Investigation
Date: Mar 31, 2025
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On-site complaint investigation of complaints 00123721, 00124081, 00124419, 00124672, 00124830, AZ00223905, AZ00223949, AZ00223967, AZ00223984, and AZ00223992 at a Nursing Care Institution, conducted 31 March 2025.
Complaint Details
The investigation of complaints 00123721, 00124081, 00124419, 00124672, 00124830, AZ00223905, AZ00223949, AZ00223967, AZ00223984, and AZ00223992 was conducted on March 31, 2025, with no deficiencies noted or cited.
Findings
This inspection found no deficiencies or citations.
Report Facts
Complaints investigated: 10
Inspection Report — Mar 5, 2025
Complaint Investigation
Date: Mar 5, 2025
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On-site complaint investigation of intakes 00116257, 00120800, AZ00223572, and AZ00223592 at a Nursing Care Institution, conducted 5 March 2025.
Complaint Details
A complaint survey was conducted on March 5, 2025 for the investigation of intake # 00116257, 00120800, AZ00223572, and AZ00223592. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 4
Inspection Report — Feb 19, 2025
Complaint Investigation
Date: Feb 19, 2025
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On-site complaint investigation of intakes AZ00223233, 00115450, and AZ00223377 at a Nursing Care Institution, conducted 19 February 2025.
Complaint Details
A complaint survey was conducted on February 19, 2025 of intake # AZ00223233, 00115450, AZ00223377. There were no deficiencies cited. Federal comments also noted complaint intakes AZ00223230, AZ00223503, and AZ00223377 with no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 3
Inspection Report — Jan 7, 2025
Complaint Investigation
Date: Jan 7, 2025
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On-site complaint investigation of intakes AZ00221560, AZ00221350, and AZ00221301 at a Nursing Care Institution, conducted 7 January 2025.
Complaint Details
A complaint survey was conducted on January 7, 2025 for the investigation of intake # AZ00221560, AZ00221350, AZ00221301. There were no deficiencies cited. Federal comments also note investigation of intake # AZ00221560, AZ00221349, AZ00221283 with no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 3
Inspection Report — Dec 26, 2024
Complaint Investigation
Date: Dec 26, 2024
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On-site complaint investigation of intakes AZ00220362, AZ00205092, AZ00204478, AZ00204995, AZ00204653, and AZ00204417 at a Nursing Care Institution, conducted 26 December 2024.
Complaint Details
An onsite complaint survey was conducted on December 26, 2024 for the investigation of intake # AZ00220362, AZ00205092, AZ00204478, AZ00204995, AZ00204653, AZ00204417. There were no deficiencies cited. An onsite complaint survey was conducted on December 26, 2024 for the investigation of intake # AZ00220359, AZ00205090, AZ00204477, AZ00204995, AZ00204653, AZ00204417. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Oct 23, 2024
Complaint Investigation
Date: Oct 23, 2024
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On-site complaint investigation of complaints AZ00216714, AZ00216787, AZ00217321, AZ00217024, and AZ00217303 at a Nursing Care Institution, conducted 23 October 2024.
Complaint Details
The complaint survey was conducted on October 23, 2024 through October 23, 2024 of the following complaint #'s AZ00216714, AZ00216787, AZ00217321, AZ00217024, and AZ00217303. No deficiencies were cited. The complaint survey was conducted on October 23, 2024 of the following complaint #'s AZ00216713, AZ00216787, AZ00217319, AZ00217024, AZ00217300. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 10
Inspection Report — Sep 18, 2024
Complaint Investigation
Date: Sep 18, 2024
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On-site complaint investigation of intakes AZ00216190, AZ00215854, AZ00214785, and AZ00214548 at a Nursing Care Institution, conducted 18 September 2024.
Complaint Details
An onsite complaint survey was conducted on September 18, 2024 for the investigation of intake # AZ00216190, AZ00215854, AZ00214785, AZ00214548. Federal comments note investigation of intake # AZ00216189, AZ00215852, AZ00214785, AZ00214547. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jul 18, 2024
Enforcement
Date: Jul 18, 2024
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Civil monetary penalty, action 00110875 (invoice INV-257769), assessed 18 July 2024.
Findings
A $500.00 penalty was assessed and paid in full on 12 December 2024.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Jul 17, 2024
Complaint Investigation
Date: Jul 17, 2024
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On-site complaint investigation of complaints AZ00213171 and AZ00213169 at a Nursing Care Institution, conducted 17 July 2024.
Complaint Details
The complaint survey was conducted on July 17,2024 for the investigation of complaint # AZ00213171. The complaint survey was conducted on July 17,2024 for the investigation of complaint # AZ00213169. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Jun 11, 2024
Complaint Investigation
Date: Jun 11, 2024
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On-site complaint investigation of complaints AZ00211503 and AZ00211501 at a Nursing Care Institution, conducted 11 June 2024.
Complaint Details
The investigation of complaints AZ00211503 and AZ00211501 was conducted on 6/11/2024. The following deficiencies were cited.
Findings
The inspection found two deficiencies related to the facility's failure to protect a resident from sexual abuse by a staff member. The facility determined the relationship was inappropriate and unprofessional but did not meet the state's definition of abuse.
Deficiencies (2)
§483.12 — The facility failed to protect resident #11 from sexual abuse by a staff member, resulting in increased risk of harm. The resident reported consensual oral sex with staff #20, but the facility did not prevent this inappropriate relationship.
R9-10-410 — The administrator failed to ensure resident #11 was not subjected to sexual abuse by staff #20. Despite interventions and monitoring, the inappropriate relationship occurred, violating resident protections.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #20 | Certified Nurse Assistant | Staff member involved in sexual abuse of resident #11. |
Inspection Report — May 20, 2024
Complaint Investigation
Date: May 20, 2024
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On-site complaint investigation of complaints AZ00210357 and AZ00210355 at a Nursing Care Institution, conducted 20 May 2024.
Complaint Details
The investigation of complaint #AZ00210357 and complaint #AZ00210355 was conducted on 5/20/24. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Mar 20, 2024
Complaint Investigation
Date: Mar 20, 2024
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On-site complaint investigation of intakes AZ00207483, AZ00207550, AZ00207482, and AZ00207549 at a Nursing Care Institution, conducted 20 March 2024.
Complaint Details
An onsite complaint survey was conducted on March 20, 2024 for the investigation of intakes #AZ00207483, and AZ00207550. Federal comments note investigation of intakes #AZ00207482, and AZ00207549. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 4
Inspection Report — Mar 14, 2024
Complaint Investigation
Date: Mar 14, 2024
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On-site complaint investigation of intake numbers AZ00177962 and AZ00177961 at a Nursing Care Institution, conducted 14 March 2024.
Complaint Details
An onsite complaint survey was conducted on March 14, 2024 for the investigation of intake # AZ00177962 and intake # AZ00177961. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 9, 2024
Complaint Investigation
Date: Feb 9, 2024
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On-site complaint investigation of intakes AZ00205919 and AZ00206204 at a Nursing Care Institution, conducted 9 February 2024.
Complaint Details
A complaint survey was conducted on 02/09/2024 for the investigation of intake AZ00205919, AZ00206204. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Dec 18, 2023
Complaint Investigation
Date: Dec 18, 2023
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On-site complaint investigation of intake numbers AZ00204285, AZ00201054, AZ00203849 and AZ00201148 at a Nursing Care Institution, conducted 18 December 2023.
Complaint Details
The complaint survey was conducted on December 18, 2023 for the investigation of intake numbers AZ00204285, AZ00201054, AZ00203849 and AZ00201148. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Nov 15, 2023
Complaint Investigation
Date: Nov 15, 2023
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On-site complaint investigation of intake numbers AZ00202710, AZ00200457, AZ00197144, AZ00201204, and AZ00200627 at a Nursing Care Institution, conducted 15 November 2023.
Complaint Details
A complaint survey was conducted on November 15, 2023 for the investigation of intake #s: AZ00202710, AZ00200457, AZ00197144, AZ00201204, and AZ00200627. Federal comments noted investigation of intake #s: AZ00202709, AZ00200455, AZ00197144, AZ00201203, and AZ00200627. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Jul 28, 2023
Complaint Investigation
Date: Jul 28, 2023
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On-site complaint investigation of intakes AZ00197835, AZ00197843, AZ00197912, AZ00197932, AZ00198167, AZ00197833, AZ00197841, AZ00197908, and AZ00197931 at a Nursing Care Institution, conducted 28 July 2023.
Complaint Details
An onsite survey was conducted on July 28, 2023 for the investigation of intake #s: AZ00197835, AZ00197843, AZ00197912, AZ00197932 and AZ00198167. A complaint survey was conducted on July 28, 2023 for the investigation of intake #s: AZ00197833, AZ00197841, AZ00197908, AZ00197931 and AZ00198167. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 10
Inspection Report — Jul 12, 2023
Complaint Investigation
Date: Jul 12, 2023
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On-site complaint investigation of complaint AZ00197567 at a Nursing Care Institution, conducted 11 through 12 July 2023.
Complaint Details
The complaint survey was conducted on July 11 through 12, 2023 for the investigation of AZ00197567 and AZ00197565. There were no deficiencies cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Jul 6, 2023
Date: Jul 6, 2023
Visit Reason
On-site inspection of a Nursing Care Institution recertification survey conducted 6 July 2023 under the Life Safety Code 2012 Edition.
Findings
The inspection found two deficiencies related to door locking and maintenance issues that could compromise patient and staff safety. The facility accepted a plan of correction for these deficiencies.
Deficiencies (2)
Delayed egress door on the 200 hall failed to open with less than 15 pounds of force, requiring 25 pounds to activate the irreversible release process, risking harm in emergencies.
Several doors failed to maintain proper latching and smoke containment, including a room 404 door that did not latch securely and kitchen and laundry doors with excessive gaps allowing smoke passage.
Report Facts
Deficiencies cited: 2
Inspection Report — Jul 6, 2023
Routine
Date: Jul 6, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, environment, transfers, medication administration, catheter care, staffing, infection control, food safety, and other aspects of care and facility operations.
Findings
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.
Deficiencies (13)
Failed to ensure an alternate food choice during meals was provided to one resident.
Failed to maintain walls and blinds in residents' rooms in good repair.
Failed to notify residents in writing of the reason for transfers and bed-hold policies.
Failed to monitor and administer medications as prescribed, including documentation omissions.
Failed to ensure hazardous chemicals were stored safely.
Failed to provide appropriate catheter care and services according to professional standards.
Failed to provide enough nursing staff to meet residents' needs and have a licensed nurse on each shift.
Failed to post accurate nurse staffing information reflecting actual hours and staff.
Failed to ensure resident did not receive pain medication outside physician's ordered parameters.
Failed to date opened glucometer control solutions, risking inaccurate blood glucose results.
Failed to ensure dishes and utensils were cleaned under sanitary conditions and spoiled/unpalatable foods were not available.
Failed to dispose of garbage and refuse properly, resulting in unsanitary conditions.
Failed to maintain infection prevention and control during catheter care.
Report Facts
Residents affected: 6
Medication errors: 5
Sanitation test result: 10
Sanitation test result: 200
Number of chef salads: 6
Number of heads of Romaine lettuce: 8
Number of frozen sausages: 15
Number of frozen beef patties: 25
Staffing hours: 21.53
Staffing hours: 31.03
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #70 | Certified Nursing Assistant | Interviewed about offering alternate food choices. |
| Staff #181 | Director of Nursing | Interviewed about food choices, transfer notifications, medication errors, staffing. |
| Staff #170 | Maintenance Supervisor | Interviewed about room repairs and maintenance. |
| Staff #111 | Licensed Practical Nurse | Interviewed about medication administration and catheter care. |
| Staff #24 | Certified Nursing Assistant | Observed and interviewed about catheter care. |
| Staff #51 | Staffing Coordinator, Certified Nursing Assistant | Interviewed about staffing levels and postings. |
| Staff #126 | Dietary Supervisor | Interviewed about dishwasher sanitation and food safety. |
| Staff #180 | Administrator | Interviewed about staffing and refuse disposal. |
Inspection Report — Jul 6, 2023
Annual Inspection
Date: Jul 6, 2023
Visit Reason
On-site complaint and annual compliance inspection of Nursing Care Institution PHOENIX MOUNTAIN POST ACUTE conducted 26 June through 6 July 2023, including investigation of intake #AZ00197343.
Complaint Details
The State compliance survey was conducted in conjunction with investigation of intake #AZ00197343. The Recertification survey was also conducted in conjunction with this intake. The facility was investigated for multiple complaint allegations.
Findings
This inspection identified 26 deficiencies including failures in policy implementation for resident transfers, insufficient alternate food choices, unsafe environment conditions, medication administration errors, staffing shortages, and infection control lapses. The facility was cited for multiple violations affecting resident care and safety.
Deficiencies (26)
R9-10-403.C — The administrator failed to ensure policies and procedures for physical and behavioral health services were established, documented, and implemented to protect residents, including proper notification and documentation of hospital transfers for residents #10 and #24.
§483.10(a) — The facility failed to provide an alternate food choice during meals to resident #12, risking the resident not receiving proper nutrition.
§483.10(i) — The facility failed to maintain walls and blinds in residents' rooms (#64, #154, #40, and #63), resulting in damaged walls and broken blinds that compromise a safe and homelike environment.
§483.15(c)(3) — The facility failed to notify residents #10 and #24 in writing of the reasons for their transfers, and the notices were not signed, dated, or mailed to the resident/representative.
§483.15(d) — The facility failed to provide residents #10 and #24 with the bed-hold policy in writing prior to hospital transfer, and no bed-hold policy was found in the clinical records.
§483.21(b)(3) — The facility failed to monitor and document administration of medications for resident #97, including omissions in medication administration records and side effect monitoring.
§483.25(d) — The facility failed to ensure hazardous chemicals were stored safely, as a bottle of bleach was left accessible in resident #64's bathroom.
§483.25(e) — The facility failed to provide proper catheter care for residents #23 and #79, including improper glove use and incomplete cleaning techniques, increasing risk of infection.
§483.35(a) — The facility failed to maintain sufficient nursing staff to meet the needs of six residents, resulting in delayed responses to call lights and unmet care needs.
§483.35(g) — The facility failed to post accurate nurse staffing information for actual hours worked and staffing totals for six of seven days reviewed.
§483.45(d) — The facility administered hydromorphone to resident #97 outside of physician-ordered parameters, resulting in unnecessary medication use.
§483.50(a) — The facility failed to date opened glucometer control solution bottles on two medication carts, risking inaccurate blood glucose test results.
§483.60(i) — The facility failed to ensure dishes and utensils were sanitized properly and stored spoiled or unpalatable refrigerated and frozen foods, risking resident illness.
§483.60(i)(4) — The facility failed to properly dispose of refuse around the large garbage compactor, resulting in unsanitary conditions and pest harborage.
§483.80 — The facility failed to maintain infection prevention and control during catheter care for resident #23, including improper glove use and cleaning technique.
R9-10-412.B.2 — The director of nursing failed to ensure sufficient nursing personnel were on premises to meet the needs of seven residents, resulting in unmet care needs and staffing shortages.
R9-10-412.B.4.d — The director of nursing failed to maintain documentation of actual hours worked by nursing personnel for six of seven days reviewed, resulting in inaccurate staffing records.
R9-10-412.B.7 — The director of nursing failed to ensure resident #97 did not receive unnecessary medication, as hydromorphone was administered outside ordered parameters.
R9-10-414.B.3.b — The administrator failed to ensure nursing care plans assisted residents in maintaining their highest practicable well-being, including proper catheter care for residents #23 and #79.
R9-10-416.8 — The administrator failed to ensure expired or unlabeled laboratory supplies, specifically glucometer control solutions, were discarded according to policy.
R9-10-422.3.e — The administrator failed to establish, document, and implement infection control training for personnel related to catheter care for resident #23.
R9-10-423.A.3.b — The administrator failed to ensure the facility could store, refrigerate, and reheat food to meet dietary needs, as spoiled and unpalatable foods were present.
R9-10-423.B.5.b — The registered dietitian or director of food services failed to provide food substitutions of similar nutritional value when requested by resident #12.
R9-10-423.B.8 — The registered dietitian failed to ensure tableware and utensils were clean and in good repair, risking resident illness.
R9-10-425.A.1.b — The administrator failed to maintain the premises free from conditions that may cause physical injury, including damaged walls and broken blinds in residents' rooms (#64, #154, #40, and #63).
R9-10-425.A.11 — The administrator failed to ensure hazardous chemicals were stored in labeled containers in a locked area separate from food and medications, as bleach was accessible in resident #64's bathroom.
Report Facts
Deficiencies cited: 26
Complaints investigated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #71 | Case Manager | Interviewed regarding notification of resident transfers |
| Staff #40 | Social Services Manager | Present during interview with Case Manager |
| Staff #146 | Medical Records Supervisor | Interviewed regarding notification of resident transfers |
| Staff #2 | Licensed Practical Nurse | Interviewed regarding discharge paperwork and notification |
| Staff #181 | Director of Nursing | Interviewed regarding multiple deficiencies including transfers, medication errors, catheter care, staffing |
| Staff #70 | Certified Nursing Assistant | Interviewed regarding alternate food choices |
| Staff #133 | Hospitality Aide | Interviewed regarding alternate food choices |
| Staff #22 | Licensed Practical Nurse | Interviewed regarding alternate food choices |
| Staff #6 | Certified Nursing Assistant | Interviewed regarding alternate food choices |
| Staff #64 | Resident | Interviewed and observed regarding room condition and chemical storage |
| Staff #154 | Resident | Interviewed and observed regarding room condition |
| Staff #40 | Resident | Observed regarding room condition |
| Staff #63 | Resident | Interviewed and observed regarding room condition |
| Staff #170 | Maintenance Supervisor | Interviewed regarding room repairs and maintenance |
| Staff #180 | Administrator | Interviewed regarding room condition and maintenance |
| Staff #111 | Licensed Practical Nurse | Interviewed regarding medication administration and catheter care |
| Staff #24 | Certified Nursing Assistant | Observed and interviewed regarding catheter care |
| Staff #124 | Assistant Director of Nursing | Observed catheter care and interviewed CNA |
| Staff #126 | Dietary Supervisor | Interviewed and observed regarding food safety and sanitation |
| Staff #138 | Cook | Interviewed regarding dishwasher sanitation |
| Staff #151 | Registered Nurse | Interviewed regarding glucometer control solution labeling |
| Staff #182 | Licensed Practical Nurse | Observed glucometer control solution labeling |
| Staff #51 | Staffing Coordinator, Certified Nursing Assistant | Interviewed regarding staffing levels and posting accuracy |
| Staff #8 | Resident | Interviewed regarding staffing concerns |
| Staff #72 | Resident | Interviewed regarding staffing concerns |
| Staff #49 | Resident | Interviewed regarding staffing concerns |
| Staff #52 | Resident | Interviewed regarding staffing concerns |
| Staff #94 | Resident | Interviewed regarding staffing concerns |
| Staff #12 | Resident | Observed and interviewed regarding food substitutions |
| Staff #79 | Resident | Reviewed clinical records for catheter care |
| Staff #23 | Resident | Reviewed clinical records and observed catheter care |
Inspection Report — May 12, 2022
Routine
Date: May 12, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, respiratory care, and dialysis services at Phoenix Mountain Post Acute nursing home.
Findings
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.
Deficiencies (3)
Failed to provide a care planned and ordered assistive device (fall mat) to a resident (#53) at high risk for falls, resulting in increased risk of injury.
Failed to ensure oxygen tubing and mask were changed for resident (#37) receiving oxygen therapy, resulting in potential respiratory complications.
Failed to ensure dialysis services were consistent with professional standards for resident (#44), including lack of documentation of pre and post dialysis assessments and dialysis center communication.
Report Facts
Fall risk score: 11
Fall risk score: 13
Oxygen saturation: 97
Oxygen saturation: 90
Oxygen saturation: 94
Oxygen saturation: 94
Oxygen saturation: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #22 | Certified Nursing Assistant (CNA) | Interviewed regarding fall risk and assistive device use for resident #53 |
| Staff #133 | Licensed Practical Nurse (LPN) | Interviewed regarding fall risk interventions and care plan for resident #53 |
| Staff #139 | Director of Nursing (DON) | Interviewed regarding fall risk review process and expectations for resident #53 |
| Staff #130 | Certified Nursing Assistant (CNA) | Interviewed regarding oxygen tubing and mask change procedures for resident #37 |
| Staff #114 | Registered Nurse (RN) | Interviewed regarding oxygen supply checks and resident #37 complaints |
| Staff #129 | Director of Nursing (DON) | Interviewed regarding dialysis care and documentation for resident #44 |
Inspection Report — May 12, 2022
Complaint Investigation
Date: May 12, 2022
Visit Reason
The inspection was conducted to investigate complaints related to resident care, including failure to provide assistive devices to prevent falls, failure to change oxygen tubing, and inadequate dialysis care.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to provide a care planned and ordered assistive device (fall mat) to a resident at high risk for falls, resulting in increased risk of injury.
Failure to ensure oxygen tubing and mask were changed for a resident on oxygen therapy, resulting in potential respiratory complications.
Failure to ensure dialysis services were consistent with professional standards, including lack of documentation of pre and post dialysis assessments and inconsistent communication from dialysis center.
Report Facts
Resident fall risk score: 11
Resident fall risk score: 13
Oxygen saturation percentages: 97
Oxygen saturation percentages: 90
Dialysis pick-up times: 9.5
Dialysis pick-up times: 13.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Interviewed regarding fall prevention and use of fall mats for resident #53 | |
| Licensed Practical Nurse (LPN) | Interviewed about fall risk and interventions for resident #53 | |
| Director of Nursing (DON) | Interviewed about fall risk assessments and dialysis care documentation | |
| Registered Nurse (RN) | Interviewed about dialysis care and oxygen therapy for residents | |
| Certified Nursing Assistant (CNA) | Interviewed about oxygen therapy equipment checks | |
| Unit Secretary | Interviewed about dialysis center documentation and communication |
Inspection Report — Jan 17, 2020
Annual Inspection
Date: Jan 17, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, treatment, and facility operations, including accuracy of assessments, care planning, treatment, medication management, and safety.
Findings
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.
Deficiencies (6)
Inaccurate MDS assessments for residents #2, #71, and #267, failing to document falls, catheter presence, and dialysis services.
Baseline care plan for resident #24 lacked necessary information regarding assistance required for activities of daily living and mobility.
Failure to take vital signs for resident #24 during a change of condition leading to hospital transfer.
Pressure ulcer for resident #92 was not thoroughly assessed timely upon admission.
Resident #24 did not maintain sufficient fluid intake; lack of interventions to address low intake and continued administration of diuretic led to hospitalization.
Medication cart on hall 300 was left unattended and unlocked; expired Nitroglycerin tablets found in medication cart on 100 hallway.
Report Facts
Deficiencies cited: 6
Fluid intake (ml): 270
Fluid intake (ml): 2010
Medication expiration dates: 3
BIMS scores: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #26 | MDS Nurse / Coordinator | Interviewed regarding inaccuracies in MDS assessments for residents #2, #71, and #267 |
| Staff #145 | Director of Nursing | Interviewed regarding expectations for MDS accuracy, care planning, vital signs monitoring, and medication storage |
| Staff #147 | Licensed Practical Nurse | Documented resident #24's change of condition and interviewed about vital signs taken during emergency |
| Staff #132 | Wound Nurse / Registered Nurse | Conducted wound treatment observation and interviewed about pressure ulcer assessments |
| Staff #80 | Certified Nursing Assistant | Interviewed about resident #24's fluid intake and assistance needs |
| Staff #150 | Registered Dietitian | Interviewed about resident #24's nutritional and fluid intake monitoring |
Inspection Report — Jan 17, 2020
Complaint Investigation
Date: Jan 17, 2020
Visit Reason
The inspection was conducted to investigate complaints regarding inaccurate Minimum Data Set (MDS) assessments, failure to create adequate baseline care plans, failure to provide appropriate treatment and care according to orders, failure to maintain adequate hydration and nutrition, failure to properly assess pressure ulcers, and medication storage issues.
Complaint Details
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.
Findings
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.
Deficiencies (6)
Inaccurate MDS assessments for residents #2, #71, and #267, including failure to document falls, indwelling catheters, and dialysis services.
Failure to create and implement a baseline care plan with necessary healthcare information for resident #24 within 48 hours of admission.
Failure to provide appropriate treatment and care according to orders for resident #24, including failure to take vital signs during a change of condition.
Failure to provide appropriate pressure ulcer care and timely assessment for resident #92.
Failure to maintain adequate hydration and nutrition for resident #24, resulting in hospitalization for severe dehydration and related complications.
Failure to ensure medication carts were locked when unattended and failure to remove expired medications from medication carts.
Report Facts
Fluid intake: 1480
Fluid intake: 1380
Fluid intake: 1410
Fluid intake: 1380
Fluid intake: 1560
Fluid intake: 1420
Fluid intake: 1580
Fluid intake: 1590
Fluid intake: 1540
Fluid intake: 1160
Fluid intake: 1408
Fluid intake: 1420
Fluid intake: 1760
Fluid intake: 1560
Fluid intake: 985
Fluid intake: 540
Fluid intake: 270
Sodium: 161
Chloride: 128
BUN: 81
Creatinine: 1.8
Osmolality: 363
Lactic Acid: 2.2
Medication expiration date: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| staff #26 | MDS Nurse / MDS Coordinator | Interviewed regarding inaccurate MDS assessments for residents #2, #71, and #267 |
| staff #145 | Director of Nursing | Interviewed regarding expectations for MDS accuracy, care plans, vital signs, and medication storage |
| staff #147 | Licensed Practical Nurse | Documented resident #24's change in condition and vital signs situation |
| staff #132 | Wound Nurse / Registered Nurse | Conducted wound treatment observation and assessment for resident #92 |
| staff #80 | Certified Nursing Assistant | Interviewed about resident #24's fluid intake and assistance needs |
| staff #150 | Registered Dietitian | Interviewed regarding resident #24's fluid provision and intake monitoring |
| staff #151 | Licensed Practical Nurse | Observed leaving medication cart unlocked |
| staff #77 | Licensed Practical Nurse | Observed medication cart with expired Nitroglycerin tablets |
Report
6 CMS Surveys
CMS Survey — Jun 11, 2024
Jun 11, 2024
CMS Survey — Jun 17, 2025
Jun 17, 2025
CMS Survey — Jul 11, 2025
Jul 11, 2025
CMS Survey — Jan 17, 2020
Jan 17, 2020
CMS Survey — May 12, 2022
May 12, 2022
CMS Survey — Jul 6, 2023
Jul 6, 2023
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