Below 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 Phoenix Mountain Post Acute during CMS and state inspections, most recent first.
Menu options did not include resident alternate meal choices. Residents stated they were not provided other meal options for breakfast, lunch, or dinner, and several were unaware of any alternate menu beyond the limited choices on the meal ticket. The Dietary Supervisor said residents could select only two entrees or request a PB&J or grilled cheese sandwich, and tray assembly observation showed meal tickets listing only two entree choices with no other substitutions.
Failure to Follow Enhanced Barrier Precautions: The facility did not consistently implement EBP for residents with catheters and other indwelling devices, as signage was missing outside several rooms and staff reported it was only checked weekly. For a resident with a G-tube and diagnoses including aphasia, hydrocephalus, dysphagia, and contractures, an LPN administered medications through the tube wearing gloves but no gown, despite the EBP sign directing staff to use both gloves and a gown for G-tube care.
Failure to consistently offer and document individualized activities for a resident with vascular dementia and severe cognitive impairment. The resident said the activities were juvenile and wanted more adult-like options, while the care plan included 1:1 interaction, sensory activities, reading, games, music, TV, and other preferred activities. Activity records showed no documentation that several planned activities were offered or refused, and the AD acknowledged missing documentation for multiple months.
A resident with hypotension and severe cognitive impairment received Midodrine outside the ordered SBP hold parameter on multiple occasions. MAR review showed the medication was administered when SBP was above 120, and the DON and RN confirmed the doses were given outside physician orders and not in line with facility expectations.
Incomplete Narcotic Count Documentation: The facility failed to ensure the Narcotic Log/Count Q shift Monitoring sheets were accurately completed for controlled medications. An LPN and the Unit Manager identified missing nurse signatures and incomplete quantity entries on medication cart logs, and the DON stated that two nurses were expected to count the narcotic card, sign the log together, and complete the quantity and initials sections. The facility policy required a physical inventory of controlled medications by two licensed nurses at each shift change and documentation on an audit record.
The facility did not ensure its AED was maintained and checked according to manufacturer guidelines, resulting in the device being non-operational when EMS responded to a resident in cardiac arrest. Documentation and daily checks were lacking, and the malfunction was not promptly reported or addressed, as confirmed by staff and manufacturer interviews.
A resident with an intellectual disability and chronic skin conditions was repeatedly observed in a disheveled, malodorous state, with stained clothing and poor hygiene, despite care plans and facility policies requiring assistance with grooming and cleanliness. Documentation showed repeated refusals of showers and a lack of evidence of bathing over a two-week period, and staff interviews indicated ongoing issues with resistance to care and insufficient re-evaluation of bowel and bladder management.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
A resident with severe cognitive impairment and under hospice care experienced a significant change in condition, including combative behavior and lack of assistance with eating, resulting in soiling and unaddressed personal care needs. Facility staff did not notify hospice services as required, and there was no documentation to support the reported events or interventions taken.
A CNA transferred a resident dependent on a Hoyer lift without a second staff member present, despite facility policy and training requiring two staff for mechanical lift transfers. Staff interviews and facility documentation confirmed the two-person requirement, but it was not followed during the observed transfer.
A resident with Schizophrenia did not receive Clozapine as ordered over a period of time, and the medication administration record inaccurately indicated that the medication was given on certain days when it was not available. Staff interviews revealed that required documentation of the medication's unavailability and related actions was not completed, resulting in clinical records that did not accurately reflect the resident's care.
A resident with a history of intimate partner violence reported a consensual but inappropriate relationship with a male staff member, involving oral sex. The facility's investigation revealed exchanged phone numbers and text messages, but the staff member denied physical contact. Despite the resident's report, the facility deemed the relationship unprofessional but not abusive under state law. Interviews with other staff highlighted the staff member's frequent visits and flirtatious behavior, raising concerns about the facility's policies on professional boundaries.
Menu options did not include resident alternate meal choices
Penalty
Summary
The facility failed to ensure that menus provided alternate meal options for residents who refused the food offered. During interviews, Resident #106 stated that the facility had not provided other meal options for breakfast, lunch, and dinner, and that the menu had changed about 6 months earlier so it no longer included alternate options. Resident #106 also stated that they had previously been able to request items such as quesadillas and beef burgers, but were unsure what options were currently available because the menu did not list any other choices. Resident #10 stated that the facility had not provided other meal options for breakfast, lunch, and dinner and reported that, although they understood their diet could be limited due to an ordered weight loss diet, they had raised concerns about the available alternatives and their preferences. Resident #103 stated that they did not eat lunch on 5 of the last 7 days because they did not enjoy heavy starches such as potatoes and pasta, and said they were unaware of an alternate menu with other food options. Resident #71 stated that there were never any options provided on the meal ticket and that they did not know how to order any other meal options. Resident #1 stated that they did not know there were other meal options and would only eat what they could from the tray, noting that they had to be mindful of certain foods because of outside dialysis services. The Dietary Supervisor stated that residents were given a weekly menu on Fridays with two main entree choices and were expected to return them by Saturday so dietary staff could accommodate the selection. The supervisor also stated that residents could request a peanut butter and jelly sandwich or a grilled cheese sandwich, but no other food options could be written on the menu requests or meal tickets. During observation of lunch tray assembly, each resident's meal ticket showed only two entree choices and no other options or substitutions. The facility policy titled 'Menu Planning' stated that regular and therapeutic menus would be written to provide a variety of foods served on different days of the week and reflect the religious, cultural, and ethnic needs of the population served, as well as input received from individuals and groups.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented for five residents, including residents with catheters, a G-tube, and other indwelling devices. Based on observation, record review, interviews, and policy review, Enhanced Barrier Precautions (EBP) were not consistently in place for residents #99, #6, #25, and #11, even though they were receiving catheter care. EBP signage was not present outside their rooms on two consecutive days, and staff reported that the signs sometimes fall off or are removed by residents and were only routinely checked every Friday. Resident #67 had diagnoses including aphasia, hydrocephalus, dysphagia, and contractures, and had a physician order for EBP every shift for the G-tube. During medication administration, an LPN was observed sanitizing hands and wearing gloves while administering medications through the G-tube, but was not observed wearing a gown. The EBP sign outside the room instructed staff to don gloves and a gown for care involving the G-tube, and unopened gowns were present in the room. The LPN stated gowns were not needed for G-tube care and believed they were only for contact isolation, while the DON stated staff were expected to follow the EBP postings and wear gloves and gowns when manipulating feeding tubes, including for medication administration.
Failure to Document and Offer Individualized Activities
Penalty
Summary
The facility failed to ensure that individualized activities were consistently offered to one resident with vascular dementia and a history of homelessness. During the initial pool, the resident stated that the activities were juvenile and childlike, that she had no interest in them, and that she wanted more adult-like activities that she could participate in. The resident’s care plan, initiated in February 2023, included interventions such as 1:1 interaction, reminiscing, sensory and comfort activities, correspondence with her sister, books, newspapers, magazines, card and word games, trivia, bingo, puzzles, music, television, movies, and going outside for 1:1 interaction. The quarterly assessment noted that the resident could state her preferences, preferred to be alone, and on occasion accepted 1:1 interaction for short periods. The quarterly MDS showed a BIMS score of 03, indicating severe cognitive impairment. Review of the activity participation task in Point Click Care showed no documentation for the last 30 days for social activities, including pet visits, meal/food/snack social, bingo, and board games. There was also no documented evidence that the activities were offered or that the resident refused to participate in the offered activities of interest. The activity task showed only two documented refusals for one-on-one activities, on August 29, 2025 and September 4, 2025. Review of progress notes revealed no documented activity progress notes. The Activity Director acknowledged there was no documentation that the resident was offered activities per the care plan for June, July, and August 2025, and stated that the expectation was for activity staff to document offered activities and refusals. The interim Administrator and AIT stated that all interactions with residents by the activity department were expected to be documented.
Midodrine Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure that Resident #6’s medication regimen was free from unnecessary drugs by administering Midodrine HCl 2.5 mg outside of the ordered parameters. The resident was admitted with hypotension and unspecified dementia, and a physician’s order dated July 1, 2024 directed that Midodrine be given three times daily for hypotension but held if systolic blood pressure (SBP) was greater than 120. The resident’s quarterly MDS showed a BIMS score of 03, indicating severe cognitive impairment. Review of the MAR showed multiple administrations of Midodrine when the resident’s SBP was above the ordered hold parameter, including several doses in August 2025 and additional doses in September 2025. During interviews, an RN stated the medication was expected to be administered according to the physician’s order and that giving it above the parameter could cause a spike in SBP, cardiac arrest, or stroke. The DON and a Clinical Resource confirmed the out-of-parameter administrations, stated this was not within facility expectations, and acknowledged that the issue had been discussed in huddle meetings without signed documentation of education completion.
Incomplete Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure the Narcotic Log/Count Q shift Monitoring sheet was accurately completed. During an observation of the medication cart for the even-numbered rooms on September 17, 2025, an LPN stated that the Narcotic Log/Count Q shift Monitoring was incomplete for September 10, 11, 13, 14, and 15, 2025. The same LPN stated there was no day shift nurse signature for September 10 and 11, 2025, and no night shift nurse signature for September 13, 14, and 15, 2025. An interview with the Unit Manager revealed that the Narcotic Log/Count Q shift Monitoring for the odd-numbered room medication cart was also incomplete, with missing nursing signatures for September 3, 7, 14, 15, and 16, 2025, and the quantity section incomplete for September 14 and 15, 2025. The LPN stated that at the start and end of the shift, nurses were expected to sign the log to accept responsibility and confirm the narcotic count was accurate, and that incomplete documentation would not be accurate. The DON stated that the oncoming and offcoming nurses were to count the narcotic card to match the record, sign the log at the same time, and complete the quantity and nurse initial sections. A policy titled Medication Administration stated that at each shift change, a physical inventory of all controlled medication is conducted by two licensed nurses and documented on an audit record.
Failure to Maintain AED in Safe Operating Condition
Penalty
Summary
The facility failed to maintain patient care equipment, specifically an Automated External Defibrillator (AED), according to the manufacturer's recommendations and ensure it was kept in safe operating condition. During an observation of the crash cart, the AED was found with a blinking green light, but the daily checkoff list did not include the AED, and there was no documentation supporting that daily checks were performed. Facility records indicated that the AED showed signs of malfunction on May 11, 2025, and the manufacturer was not contacted until May 15, 2025, at which point the facility was instructed to remove the AED from use until a new battery was available. Documentation failed to show that the AED was checked daily or that the manufacturer's recommended documentation procedures were followed. A complaint was filed after Emergency Medical Services (EMS) responded to a resident in cardiac arrest and found the AED was not operational. Interviews with staff and the AED manufacturer confirmed the delay in reporting the malfunction and the lack of routine maintenance as outlined in the user manual. The facility's Cardiopulmonary Resuscitation policy included the use of an AED if available, but there was no crash cart policy, and the procedure relied on night staff nurses to perform daily checks, which were not documented for the AED.
Failure to Ensure Proper Grooming and Hygiene for Resident with Intellectual Disability
Penalty
Summary
A resident with an intellectual disability, adjustment disorder, pyoderma gangrenosum, and psoriasis vulgaris was not properly groomed or provided with adequate hygiene. The resident's care plan indicated a need for assistance with self-care and mobility, with goals for cleanliness and grooming. Despite being cognitively intact and assessed as capable of independent self-care, facility documentation showed repeated refusals of showers and a lack of evidence that the resident received a bath over a two-week period. The clinical record did not support that the interdisciplinary team re-evaluated the resident's bowel and bladder management on a quarterly basis as required by policy. Observations by the compliance officer and staff revealed the resident was disheveled, malodorous, with visible skin flaking, stained clothing, and a walker with a brown dried substance. Interviews with another resident and staff confirmed the resident was often seen in this state and that staff attributed it to resistance to care, while also stating efforts were made to respect the resident's independence. Facility policies required staff to ensure residents are well-groomed and clean, but these standards were not met for this resident during the review period.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Notify Hospice of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify hospice services following a significant change in condition for a resident who was admitted with hepatic encephalopathy, dementia, anxiety, and was under hospice care for a terminal cardiac diagnosis. On the morning in question, the resident was observed lying in bed with visible soiling, spilled food, and dirty clothing, indicating a lack of assistance with eating and personal care. Staff interviews revealed that the resident had been combative during breakfast, resulting in a mess, and that staff were instructed to step away and return later when the resident was calmer. However, there was no documentation in the clinical record to support the occurrence of a combative episode or the interventions taken. Further review showed that hospice was not informed of the resident's change in condition, despite contractual and policy requirements mandating immediate notification of hospice for significant changes in a hospice patient's status. The hospice RN confirmed that they had not been contacted and emphasized the importance of such communication for collaborative care. The facility was unable to provide requested documentation or surveillance footage to support staff accounts or demonstrate appropriate follow-up, highlighting a failure to ensure proper coordination with hospice services and adherence to care policies.
Failure to Follow Two-Person Hoyer Lift Policy During Resident Transfer
Penalty
Summary
A certified nursing assistant (CNA) was observed transferring a resident who required a Hoyer lift for all transfers without the assistance of a second staff member, contrary to facility policy and training. The resident had diagnoses of type 2 diabetes and muscle weakness, and was care planned as dependent on staff for all transfers, including bed, chair, toilet, and shower/tub. Facility documentation, including the facility assessment and policy, specified that two staff members are required for all mechanical lift transfers to ensure safety. Multiple staff interviews confirmed that the expectation and training were for two staff to be present during Hoyer lift use. Despite this, the CNA proceeded with the transfer alone, acknowledging in a subsequent interview that they were aware of the requirement for two staff but did not have a second person present during the observed transfer. Other staff, including another CNA, an LPN, and the Director of Nursing, all confirmed the two-person policy and recent training on this requirement. The facility's policy explicitly stated that two healthcare personnel must be present for mechanical lift transfers, but this was not followed during the incident.
Failure to Accurately Document Medication Administration and Unavailability
Penalty
Summary
The facility failed to ensure accurate clinical record documentation regarding the administration of Clozapine for one resident diagnosed with Schizophrenia. The resident had an order for Clozapine 25 mg daily, which was to be administered alongside regular lab monitoring. Review of the medication administration record for a specified period showed that the medication was only documented as given on three specific days, with no documentation for the remaining days. Interviews with staff revealed that the medication was not available during this period, and the administration entries for those three days were incorrect, as the medication had not actually been administered. Staff interviews indicated that the facility's protocol requires staff to search for medications in additional storage areas if not found in the designated cart, and to contact the provider and pharmacy if the medication remains unavailable. Staff are also expected to document all actions taken, including communications and directives, in the resident's electronic health record. However, for this resident, there was a lack of accurate documentation explaining the missed doses and the steps taken to address the medication unavailability. The Director of Nursing confirmed that the medication was not available at all during the period in question and that the documentation indicating administration on three days was incorrect. The facility's policy emphasizes the importance of complete and accurate documentation to provide a full account of resident care and to guide providers in prescribing appropriate treatments. The failure to accurately document the administration and unavailability of Clozapine resulted in clinical records that did not correctly reflect the resident's care during the specified timeframe.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by a staff member. The resident, who had a history of intimate partner violence and was at risk of re-traumatization, reported an inappropriate relationship with a non-caregiving staff member. The resident's care plan indicated a preference for female caregivers due to her history, but the relationship with the male staff member involved consensual oral sex on two occasions. The facility's documentation and interviews revealed that the resident exchanged phone numbers with the staff member, and their relationship progressed to physical contact, including kissing and touching. The facility's investigation included interviews with the resident and staff, as well as a review of text messages exchanged between the resident and the staff member. The staff member admitted to exchanging phone numbers but denied any physical contact. Despite the resident's report of a consensual relationship, the facility determined that the relationship was inappropriate and unprofessional but did not constitute abuse under the state's Adult Protective Services statute. The facility's self-report concluded that there were no patterns or instances of other unprofessional relationships. Interviews with other staff members revealed that the staff member frequently visited the resident's room and engaged in flirtatious behavior. The facility's employee handbook and policy on resident rights emphasized the importance of maintaining professional boundaries and prohibited personal or romantic involvement with residents. However, the facility's response to the incident, including the handling of the staff member's employment status, raised concerns about the adequacy of their policies and procedures in preventing and addressing such incidents.
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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) |
|---|---|---|---|---|
| Arizona State Veteran Home-phx | 1.9 mi | ★★★★★ | 2 | 0 |
| Ridgecrest Post Acute | 2.4 mi | ★★★★★ | 2 | 0 |
| Life Care Center Of Paradise Valley | 2.6 mi | ★★★★★ | 9 | 0 |
| Vi At Grayhawk, A Vi And Plaza Companies Community | 5.5 mi | ★★★★★ | 0 | 0 |
| Acacia Health Center | 5.6 mi | ★★★★★ | 3 | 0 |
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