Phoenix Mountain Post Acute

In the surveyor’s words

From the most serious findings on record at Phoenix Mountain Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 11, 2024

  Based 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. Findings include: Resident #11 admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included Wernicke's encephalopathy, anxiety, post-traumatic stress disorder, migraines, major depressive disorder, and suicidal behavior. The care plan initiated on 09/25/2023 indicated she preferred a female caregiver relation to her risk of re-traumatization related to a history of intimate partner violence. […]

• No harm, potential for more than minimal, patternF803Nov 19, 2025

  Based 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. Findings include:An initial screening interview was conducted with Resident #106 on September 16, 2025 at 8:55 AM who stated that the facility had not provided other meal options for breakfast, lunch, and dinner. Resident #106 showed this surveyor their breakfast meal tray, which was still present on the resident's bedside table during the interview and appeared untouched. […]

• No harm, potential for more than minimal, patternF880Nov 19, 2025

  Based 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. Findings include: Based on the resident matrix and a review of resident records, Residents #25, #6, #99, and #11 were receiving catheter care. […]

• No harm, potential for more than minimal, patternF908Jul 11, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF584Jul 6, 2023

  Based 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. Findings include: -Resident #64 was admitted to the facility on [DATE] with diagnoses that included anxiety, morbid obesity, and diabetes. The census record revealed that the resident was transferred to room [ROOM NUMBER] on December 21, 2022. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. […]