South Mountain Post Acute
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
documentation that the provider was notified of the held medication. Additionally, prior to the resident being transferred to the hospital on November 12, 2025, vital signs were not obtained and documented, limiting
the provider's ability to assess the resident's condition and potentially delaying appropriate medical intervention.Review of the progress nursing notes, effective date November 12, 202,5 4:34 PM revealed a nursing note documenting Confirmed with AMR that transport nonemergent will arrive by 1610.Review of
the progress nursing notes, effective date November 12, 202,5 6:20 PM, revealed a nursing note documenting x3 attempts to speak with charge at BUMC ED with no success to provide report. Was picked by AMR and family following in a private vehicle. The report was given at the bedside to paramedics. All pertinent documentation was given to the driver.An interview was conducted on December 30, 2025, at 12:41 PM with Registered Nurse (RN/Staff #9). RN/Staff#9 stated that most of the facility's blood pressure medications do not have parameters and that nurses have to rely on their nursing judgement. Staff #9 stated it is the nurse's responsibility to obtain the vital signs due to the nurses not receiving the vital signs until 10 am from the certified nursing assistants, and that blood pressure medications are due at 8 am. Staff #9 stated if medications are held,d the provider should be notified and obtain an order for parameters and a care plan for the new parameters. Staff #9 stated that the risk of not informing the provider of held medications is that staff will continue to administer medications as ordered by the MAR, not realizing the medication had been held. Staff #9 stated the facility process for residents sent to the hospital is to obtain a new set of vital signs, and the risks in not obtaining a new set prior to discharge to the hospital is the hospital will not know what the resident's baseline is; if it is higher or lower when they left the facility. An
interview was conducted on December 30, 2025, at 1:22 PM with Certified Nursing Assistant (CNA/Staff #4). Staff #4 stated vital signs are obtained before a resident is sent to the hospital, and when they return from the hospital, vital signs are obtained and are reported directly to the nurse.An interview was conducted on December 30, 2025, at 1:47 PM with the Director of Nursing (DON/Staff#12). The DON states the facility's process for blood pressure medications is to obtain vital signs before administering the medication. The DON stated if the blood pressure medication is held the provider should be notified. The DON reviewed the November 2025 MAR and confirmed that resident #33 order for Amlodipine 5mg was held on November 1, 2025, and November 6, 2025. During the interview on the DON confirmed she was unable to locate documentation of provider notification related to the held blood pressure medication and acknowledged that vital signs were not obtained before hospital transfer. The DON did not provide any risks
in not notifying the provider for held medications when questioned. This failure placed the resident at risk for delayed diagnosis, treatment, and potential harm. The DON stated the risks in not obtaining vital signs
before hospitalization is there are no baseline vital signs for the resident at the receiving facility. Review of
the facility policy titled Medication Administration, last revised June 2024, states that it is the policy of this facility that medications shall be administered as prescribed by the attending physician.1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and
record the administration of medications.Review of the facility policy titled Admission, Transfer, and Discharge last revision December 2024, states that It is the policy of this Facility that each resident will remain in the Facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the Facility shall ensure that
the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
Event ID:
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If continuation sheet
South Mountain Post Acute in PHOENIX, AZ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PHOENIX, AZ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from South Mountain Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.