Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 South Mountain Post Acute during CMS and state inspections, most recent first.
A resident with complex medical needs had antihypertensive medication held on two occasions due to low blood pressure, but the provider was not notified as required. Additionally, vital signs were not obtained or documented prior to the resident's transfer to the hospital, contrary to facility policy. Staff interviews and record review confirmed these omissions.
A resident with end stage renal disease and moderate cognitive impairment did not receive consistent monitoring before and after hemodialysis, as required by physician orders. Documentation showed missing or incorrectly timed vital sign recordings, and staff interviews revealed confusion due to transportation issues and outdated orders in the system.
A resident with type 2 diabetes was not administered insulin Glargine as per hospital discharge orders upon admission to the facility. Despite elevated blood glucose levels, the correct insulin dosage was not ordered until several days later. Staff interviews revealed a lack of clarity in the process of reviewing and entering discharge orders into the EMDR, leading to the omission of the insulin order.
A resident with dysphagia and specific dietary needs was served ice cream, which is not suitable for their nectar thick liquid diet, leading to coughing. Staff interviews revealed a lack of understanding and communication regarding the resident's dietary restrictions, with the CNA and LPN unsure about the appropriateness of ice cream for the resident's diet. The dietary manager and Registered Dietician Consultant confirmed that ice cream should not be served to residents on nectar thick diets due to choking risks.
A resident with multiple health issues was frequently observed in a state of undress with her room door open, compromising her dignity. Despite being care planned to prefer wearing her gown off the shoulders, staff failed to ensure her privacy, as confirmed by multiple observations and staff interviews. The facility's policy mandates treating residents with dignity and respect.
A resident was administered Oxycodone-Acetaminophen outside the prescribed pain parameters, leading to unnecessary medication use. Despite policies requiring adherence to physician orders and accurate pain assessment, staff administered the medication for pain levels below the prescribed threshold. Interviews with an LPN and the DON highlighted the importance of following medication protocols to prevent potential risks.
The facility failed to provide proper catheter care for two residents, leading to potential risks of infection. One resident's catheter bag was observed dragging on the floor, while another resident's records lacked documentation and physician orders for catheter care. Staff interviews revealed inconsistencies in following facility policies, contributing to the deficiencies.
A facility failed to ensure accurate documentation of catheter care for a resident with an indwelling catheter. Despite orders for care every shift, records showed care was not conducted on 8 out of 27 days. A CNA documented care as completed when it had not been performed, confirmed by the resident and staff interviews. Facility policy requires documentation post-care to ensure hygiene and reduce infection risk.
Failure to Notify Provider of Held Antihypertensive Medication and Omission of Pre-Transfer Vital Signs
Penalty
Summary
A resident with multiple complex medical conditions, including heart failure, hypertension, diabetes mellitus, respiratory failure, and acute pyelonephritis, was admitted to the facility and later discharged to the hospital. The resident had an active order for Amlodipine Besylate 5 mg daily for hypertension, with instructions to monitor vital signs every shift. On two occasions, the resident's blood pressure medication was held due to low blood pressure readings, but there was no documentation that the provider was notified of the held medication as required by facility policy. Additionally, prior to the resident's transfer to the hospital, vital signs were not obtained and documented, which limited the provider's ability to assess the resident's condition before hospitalization. Interviews with nursing staff and the DON confirmed that the facility's process requires obtaining vital signs before administering blood pressure medication and before hospital transfer, and that the provider should be notified when medications are held. However, review of the medical record and interviews revealed that these steps were not followed in this case. Facility policy on medication administration and transfer/discharge requires medications to be administered as prescribed and for appropriate documentation and communication during transfers. The DON confirmed the absence of documentation regarding provider notification for the held medication and acknowledged that vital signs were not obtained prior to the resident's hospital transfer, as required by facility procedures.
Failure to Ensure Proper Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper monitoring for a resident receiving hemodialysis, as evidenced by inconsistent documentation and implementation of physician orders for pre- and post-dialysis vital signs. The resident, who had end stage renal disease, hemiplegia, and moderate cognitive impairment, was scheduled for dialysis multiple times per week. Review of the care plan and physician orders indicated that vital signs and weight were to be obtained before and after each dialysis session, with significant changes to be reported immediately. However, documentation revealed that on certain dates, pre- and post-dialysis vital signs were either not recorded or were recorded on days when dialysis was not performed. Interviews with staff, including an LPN and the DON, confirmed that there were ongoing issues with transportation for the resident, leading to changes in dialysis scheduling and confusion regarding the correct days for monitoring and documentation. The DON acknowledged that the correct orders were not updated in the system, resulting in staff performing and documenting vital signs on incorrect days. The facility's policy required accurate implementation of physician orders, but this was not consistently followed, leading to lapses in monitoring for the resident undergoing dialysis.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that a resident received long-acting insulin as per hospital discharge orders upon admission. The resident, who was admitted with type 2 diabetes mellitus, Parkinson's disease, and dementia, was supposed to continue insulin Glargine 15 units twice daily according to the hospital's final orders. However, there was no evidence of physician orders for Insulin Glargine from February 13th to 19th, despite the attending physician reviewing and concurring with the discharge plan. The resident's blood glucose levels were monitored, showing significant fluctuations and elevated levels, including a reading of 572.0 mg/dL on February 18th. Despite these fluctuations, nursing progress notes inaccurately documented the resident's blood glucose as well controlled. It wasn't until February 20th that a Family Nurse Practitioner ordered a low dose of Glargine, which was inconsistent with the hospital's discharge instructions. The resident's blood glucose levels continued to be elevated, and adjustments to insulin dosages were made over the following days. Interviews with staff revealed a lack of clarity and communication regarding the implementation of discharge orders. A Licensed Practical Nurse stated that discrepancies in orders should be caught and clarified with the provider. The Director of Nursing and Medical Records Director confirmed that the process for reviewing and entering orders into the EMDR was not followed correctly, leading to the omission of the Glargine order. The facility's policy required that admission orders be reviewed and transcribed accurately, which was not adhered to in this case.
Failure to Follow Diet Orders for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that diet orders were followed for a resident with specific dietary needs. The resident, who was admitted with conditions including hemiplegia, end-stage renal disease, and dysphagia, had a physician order for a regular diet with mechanical soft texture and nectar thick liquids. During a dining observation, the resident was served ice cream, which is not considered a nectar thick liquid, and this led to the resident coughing. The CNA assisting the resident was unaware that ice cream should not be served, and the resident's spouse suggested adding thickener to the ice cream, which is against dietary guidelines. Interviews with staff revealed a lack of understanding and communication regarding the resident's dietary restrictions. The LPN was unsure if ice cream was appropriate for the resident's diet and would refer to dietary if uncertain. The dietary manager confirmed that ice cream should not be served to residents on nectar thick diets due to the risk of choking. The Registered Dietician Consultant also stated that ice cream should not be served and that thickener should not be added to it. The Director of Nursing acknowledged the importance of adhering to diet orders to prevent potential aspiration risks.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #23, who was admitted with multiple diagnoses including metabolic encephalopathy and end-stage renal disease. Observations revealed that the resident was frequently exposed in her room with the door open, allowing staff and other residents to see her in a state of undress. On multiple occasions, the resident was found with her upper body exposed, and staff members walked by without addressing the situation. The care plan noted that the resident preferred to wear her gown off the shoulders, but this preference was not managed in a way that maintained her dignity. Interviews with staff, including a shower aide and the Director of Nursing (DON), confirmed that the resident's state of undress was visible from the hallway, and it was acknowledged as a dignity issue. The DON stated that while the resident's preference was documented in the care plan, it was the facility's responsibility to educate the resident and ensure her dignity was preserved. Despite the acknowledgment of the dignity issue, no complaints had been received from other residents, and the facility's policy emphasized treating all residents with kindness, dignity, and respect.
Failure to Follow Pain Medication Orders
Penalty
Summary
The facility failed to adhere to a physician's order for administering pain medication to a resident, leading to the administration of unnecessary drugs. The resident, who was admitted with conditions including a cutaneous abscess and muscle weakness, was prescribed Oxycodone-Acetaminophen to be given as needed for pain levels between 6 and 10. However, the medication was administered on multiple occasions when the resident's pain level was below the prescribed threshold, specifically on four separate days in July 2024, with pain levels recorded at 3 or 4. Interviews with staff revealed a lack of adherence to the prescribed pain management protocol. An LPN acknowledged the importance of assessing pain accurately and the risks associated with administering medication outside of ordered parameters, such as potential overdose or drug interactions. The DON emphasized the necessity of following the 7 rights of medication administration and correlating pain levels with medication orders. The facility's policies on medication administration and pain management were reviewed, highlighting the requirement for verifying medication orders and documenting interventions, yet these protocols were not followed in this instance.
Deficient Catheter Care in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care and services related to indwelling urinary catheters for two residents, leading to potential risks of urinary catheter complications and urinary tract infections. Resident #164, who was admitted with diagnoses including encephalopathy and obstructive uropathy, had an indwelling catheter. Observations revealed that the resident's catheter bag was uncovered and dragging on the floor while being wheeled through the facility, contrary to the care plan and facility policy. Interviews with staff confirmed that the catheter should have been covered and properly positioned to prevent infection, and it was noted that the resident had recently experienced a urinary infection. Resident #300, admitted with diagnoses such as fluid overload and neuromuscular dysfunction of the bladder, also had deficiencies in catheter care. There were no physician orders or documentation for catheter care in the resident's records, and the care plan did not address the presence of an indwelling catheter. Interviews with staff indicated that catheter care should have been documented and provided according to facility policy, which was not reflected in the resident's medical records. The facility's policy required daily catheter care and documentation under the toileting task, which was not adhered to during the resident's stay. The facility's failure to adhere to its own policies and procedures for catheter care, as well as the lack of proper documentation and physician orders, contributed to the deficiencies observed. The staff interviews highlighted a lack of consistent practice and understanding of the requirements for catheter care, which could lead to increased risks of infection and complications for residents with indwelling catheters.
Inaccurate Documentation of Catheter Care
Penalty
Summary
The facility failed to ensure accurate clinical record documentation for a resident regarding catheter care. The resident, who was admitted with diagnoses including obstructive reflux uropathy and type 2 diabetes mellitus, had a physician's order for indwelling catheter care to be completed every shift. However, a review of the Plan of Care (POC) Response History revealed that catheter care was not conducted every shift on 8 out of 27 days. On one occasion, a Certified Nursing Assistant (CNA) documented that catheter care was completed when it had not been performed, as confirmed by both the resident and the CNA during interviews. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that catheter care was expected to be performed and documented every shift. The facility's policy on indwelling catheter care and documentation requires that care be documented after it is completed to ensure hygiene, comfort, and reduced infection risk. The inaccurate documentation by the CNA, who admitted to mistakenly recording the task as completed, led to the deficiency, potentially resulting in inaccurate and incomplete reflection of the resident's status in clinical records.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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| Desert Peak Care Center | 0.6 mi | ★★★★★ | 9 | 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 August 2026) and official state health department websites.