The Phoenix Post-Acute

In the surveyor’s words

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

• Immediate jeopardy, patternF678Oct 16, 2024

  Based on interview and record review the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 5 residents (CR#1) reviewed for CPR. CNA A and CNA M failed to initiate life-saving measures (CPR) when CR#1 who had a full code status (all resuscitation procedures provided if their heart stops beating or they stop breathing) immediately when he was found unresponsive on [DATE] around 1:30 AM. EMS was called around 1:40 AM, arrived at 1:45 AM, and began CPR. CR#1 was transported to the hospital via emergency services, where he died on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 8:35p.m. […]

• Immediate jeopardy, patternF689Oct 16, 2024

  Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (CR #1) reviewed for supervision. The facility failed to provide sufficient supervision to CR#l on [DATE] at 1:30am, when he was found unresponsive behind the facility, with blood coming from his mouth. CR#l was transported to the hospital via emergency services, where he was pronounced deceased on [DATE]. Multiple staff working the night shift (CNA E, CNA A, CNA M, CNA C and Nurse T), were unaware CR#1 was missing from the facility and an elopement code was not initiated. There was not an effective system in place to track residents entering and exiting the building. An Immediate Jeopardy (IJ) was identified on [DATE]. […]

• Immediate jeopardy, patternF686Jan 26, 2024

  Based on interviews and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #37) of 3 residents reviewed for pressure ulcers. The facility failed to notify Resident #37's physician and modify his interventions when he refused to wear his protective boot on his left foot and when he refused to be repositioned in bed. The facility failed to accurately assess and modify interventions for Resident #37, whom the facility said prefers to lie on his abdomen, and he had a suprapubic catheter. […]

• Actual harm, patternF697Jan 26, 2024

  Based on observation, interview, and record review, the facility failed to ensure pain management provided for one resident (Resident #25) of five residents reviewed for pain was consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -The facility did not have Resident #25's pain medication (Norco 7.5/325 mg) available. -Resident #25 missed 9 doses of Norco 7.5/325 mg over 5 days. -Resident #25 said her pain level was high during the time of the missed doses. The deficient practice caused Resident #25 to experience unnecessary pain. […]

• No harm, potential for more than minimal, widespreadF921Aug 1, 2023

  Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable, environment for residents, staff and the public for two (Floor 200 & 300) of two floors reviewed for environment. The facility failed to ensure walls, floor, baseboard, ceiling, and sheetrock were clean and in good repairs for: Rooms on the second Floor 201, 202, 205, 206, 207, 220, 221, 223, 228, 230, 233, 234 & common area. Rooms on the third Floor 316, 330, & 335 and lounge area. […]