Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Mountain Medical And Rehabilitation Center during CMS and state inspections, most recent first.
Infection control failed when multiple residents with atypical rashes or suspected scabies received Permethrin and other treatment without documented contact isolation or the usual linen/clothing handling measures. A roommate pair was involved, and several other residents had persistent itching, rash, or prophylactic treatment with incomplete documentation of isolation precautions. The report also cites a hand hygiene failure for one resident and failure to follow enhanced barrier precautions for another resident.
A resident with diabetes and severe cognitive impairment received Lantus (insulin glargine) injections at bedtime despite physician orders to hold the insulin when blood glucose was below a specified threshold. MAR review showed multiple administrations of both 20-unit and 15-unit Lantus doses when blood glucose readings were under the ordered hold parameter, with no documentation that the provider was notified or that new orders were obtained. In interviews, an RN and the DON confirmed that insulin is expected to be given only within ordered parameters and that no documentation existed to explain or authorize these out-of-parameter doses, contrary to facility policies requiring adherence to written physician orders and clarification of any irregularities before drug administration.
A resident with intact cognition and complex medical conditions reported an incident where a dietary staff member became aggressive after a meal complaint. The staff member allegedly twisted the resident's ankle, leading to a physical altercation. Interviews revealed discrepancies in staff accounts, and the facility's policy supports the resident's right to self-determination and to receive visitors of their choosing.
A resident with intact cognition and mobility dependence reported an incident of physical abuse by a dietary staff member after complaining about a meal. The staff member, not assigned to the resident, entered the room and allegedly twisted the resident's ankle during a confrontation. Conflicting accounts from staff interviews revealed the staff member attempted to reason with the resident, leading to an escalation where water bottles were thrown. The facility's policy on abuse prevention was not followed, as the staff member did not leave the room when requested.
Infection Control Failures With Suspected Scabies and Related Precautions
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program for multiple residents with atypical rashes that were treated as suspected scabies or similar contagious skin conditions. For Resident #155, the record showed a rash on the arms, hands, back, and abdomen that persisted over time, with treatment orders for triamcinolone and later Permethrin cream. The chart did not show contact isolation precautions, and there was no evidence that clothing, bedding, or non-washable items were handled in a way consistent with scabies control. Resident #155 shared a room with Resident #36 during the same period. Resident #36, who was roommates with Resident #155, was treated preventatively with Permethrin cream even though no rash was documented at the time. The record again did not show contact isolation precautions or evidence that clothing, towels, bedding, or non-washable items were managed to control spread. The shared room was not deep cleaned until later, and the documentation indicated the cleaning was part of a recurring schedule rather than tied to the isolation-related event. The same pattern was documented for several other residents. Resident #50 had itching and a rash that was later treated with Permethrin and ivermectin after dermatology evaluation, but the record did not show isolation precautions or evidence of washing clothing and bedding or bagging non-washable items. Resident #185 had recurrent itching and rash, later received Permethrin after dermatology evaluation, and the chart did not show the same infection-control steps. Resident #186 also received prophylactic Permethrin and contact/droplet isolation orders despite documentation that no rash was present, but the record excerpt does not show the same environmental and linen-handling measures. The report also states that staff failed to perform hand hygiene for one resident and failed to follow enhanced barrier precautions for another resident.
Insulin Administered Outside Ordered Blood Glucose Parameters
Penalty
Summary
The deficiency involves the administration of insulin outside of ordered parameters, resulting in unnecessary medication for a resident. The resident was admitted with diagnoses including nontraumatic intracerebral hemorrhage, type 2 diabetes mellitus with hyperglycemia, and metabolic encephalopathy. A physician’s order dated July 22, 2025, directed that Lantus (insulin glargine) 20 units be given subcutaneously at bedtime for diabetes mellitus and held if blood glucose was under 120. This order was later discontinued on November 9, 2025, and replaced with a new order for Lantus 15 units at bedtime with the same instruction to hold if blood glucose was under 120. A quarterly MDS assessment documented that the resident had memory problems, severely impaired cognitive skills, and had received a daily injection for seven days prior to the assessment. Review of the November 2025 MAR showed that Lantus 20 units was administered on November 4 and 5 when the resident’s blood glucose readings were 117 and 118, respectively, which were below the ordered hold parameter of 120. After the dose was changed to 15 units on November 9, the MAR showed that Lantus continued to be administered outside the ordered parameters on multiple dates: November 16 with a blood glucose of 113, November 19 with 90, November 20 with 98, November 22 with 88, and November 23 with 86. These administrations occurred despite the standing order to hold the insulin if blood glucose was under 120. Further review of the clinical record revealed no evidence that the provider was notified about the resident’s blood sugar status or that Lantus had been administered outside the ordered parameters on any of those dates, and there were no updated orders or documented rationale for giving the medication outside parameters. In interviews, an RN stated that insulin must be administered within provider-ordered parameters and that administering insulin outside of orders could cause hypoglycemia, and also stated that the only exception would be if the provider had ordered it. The DON confirmed that the Lantus doses had been given outside the ordered blood glucose parameters and that there was no documentation of provider notification or updated orders, and stated that staff are expected to hold medications when results fall outside ordered parameters and to document the occurrence in progress notes. Facility policies on physician orders and medication administration required that medications be administered only in accordance with written physician orders and that any irregularity or question regarding dosage be clarified with the physician before administration.
Resident's Right to Deny Visitors Violated
Penalty
Summary
The facility failed to ensure a resident's right to receive and deny visitors, which resulted in a deficiency. The resident, who was admitted with diagnoses including acute and chronic respiratory failure, had a BIMS score indicating intact cognition. The care plan noted a potential risk for cognitive loss and ineffective coping skills, with interventions to encourage communication with family and caregivers. An incident was reported where the resident alleged that a dietary staff member became aggressive after the resident complained about a meal. The incident involved a dietary staff member who entered the resident's room after the resident complained about a burnt hamburger patty. The staff member reportedly became upset and yelled at the resident, leading to a physical altercation where the staff member allegedly twisted the resident's ankle. The resident responded by throwing a water bottle at the staff member, who then retaliated by throwing water bottles at the resident and tipping over a urinal, leaving the resident soaked. Interviews with staff revealed discrepancies in the accounts of the incident. The dietary staff member claimed she was trying to reason with the resident and did not intend to harm him, while the CNA assigned to the resident stated there was no communication about the dietary staff member visiting the resident's room. The Director of Nursing emphasized that staff should leave a resident's room when requested to avoid upsetting the resident and ensure they are free from abuse. The facility's policy on residents' rights supports the resident's right to self-determination and to receive visitors of their choosing.
Resident Abuse Incident Involving Dietary Staff
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse, as evidenced by an incident involving a dietary staff member and a resident. The resident, who was admitted with diagnoses including acute and chronic respiratory failure, had intact cognition and was dependent on staff for mobility. The resident reported an incident where a dietary staff member became upset after he complained about his meal and allegedly twisted his ankle, leading to a physical altercation where water bottles were thrown, and the resident was soaked with urine and water. Interviews with staff revealed conflicting accounts of the incident. The dietary staff member involved, who was not assigned to the resident, admitted to entering the resident's room and attempting to reason with him about the meal. The staff member claimed that the resident attempted to kick her, prompting her to reflexively move his leg, although she denied grabbing it. The staff member acknowledged that the situation escalated, resulting in the resident throwing water at her, which prompted her to leave the room. The facility's policy on abuse prevention was reviewed, highlighting the resident's right to be free from abuse and mistreatment. The Director of Nursing stated that staff should leave a resident's room if requested to avoid upsetting the resident. The incident was not handled according to the facility's expectations, as the staff member did not leave the room when asked, leading to a situation that could have been avoided.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Terraces Of Phoenix | 2 mi | ★★★★★ | 0 | 0 |
| Coronado Healthcare Center | 2.2 mi | ★★★★★ | 4 | 0 |
| Christian Care Nursing Center | 2.4 mi | ★★★★★ | 9 | 0 |
| Maryland Gardens Post Acute | 2.7 mi | ★★★★★ | 0 | 0 |
| Beatitudes Campus | 2.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.