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NORTH MOUNTAIN MEDICAL AND REHABILITATION CENTER

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NORTH MOUNTAIN MEDICAL AND REHABILITATION CENTER VS
Nursing Homes USA
General
City PHOENIX   0.2% Nursing Homes USA have PHOENIX
State attribute explanation AZ   0.9% Nursing Homes USA have AZ
Street 9155 NORTH THIRD STREET  
Zip Code 85020  
Phone 6029441666  
Overall Star Rating
3.11
Health Inspections Star Rating
2.83
Nurse Staffing Star Rating
3.17
Quality Measures Star Rating
3.31
RN Only Star Rating
3.17
Number of Certified Beds
155 
108.94
Total Number of Residents
147 
91.25
Percent of Occupied Beds
95 %
83.65 %
Health Survey Date 10/24/2011  
Fire Survey Date 10/21/2011  
Sprinkler Status Fully Sprinklered  90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Corporation  56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? Yes  54.9% Nursing Homes USA have Multi Nursing Home Ownership?
Resident and Family Councils Both  29.8% Nursing Homes USA have Both
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? Yes  31.3% Nursing Homes USA have Quality Indicator Survey?
Special Focus Facility? No  99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
75.2 
58.16
Total Enforcement Actions Count
75.2 
56.31
# of deficiencies 31  
Staff Information
Number of Residents
147 
91.38
Number of RN Hours Per Resident Per Day
1.07 
0.77
Number of LPN/LVN Hours Per Resident Per Day
1.35 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
2.42 
1.59
Number of CNA Hours Per Resident Per Day
0.07 
5.49
Number Therapy Hours Per Resident Per Day
0.07 
0.10
Environmental Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 04/15/2009
date Of Correction: 05/08/2009 
Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #3 Scope: Some
level Of Harm: 3
deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #5 Scope: Some
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 04/15/2009
date Of Correction: 05/08/2009 
Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 04/15/2009
date Of Correction: 05/08/2009 
Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 08/19/2010
date Of Correction: 10/04/2010 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 08/27/2009
date Of Correction: 10/07/2009 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Try To Resolve Each Resident's Complaints Quickly.
survey Date: 04/15/2009
date Of Correction: 05/08/2009 
Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 05/17/2012
date Of Correction: 06/12/2012 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 08/19/2010
date Of Correction: 10/04/2010 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Have Enough Nurses To Care For Every Resident In A Way That Maximizes The Resident's Well Being.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #4 Scope: Few
level Of Harm: 3
deficiency: Give Proper Treatment To Residents With Feeding Tubes To Prevent Problems (such As Aspiration Pneumonia, Diarrhea, Vomiting, Dehydration, Metabolic Abnormalities, Nasal-pharyngeal Ulcers) And Help Restore Eating Skills, If Possible.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #5 Scope: Few
level Of Harm: 3
deficiency: Make Sure That Each Resident Who Enters The Nursing Home Without A Catheter Is Not Given A Catheter, And Receive Proper Services To Prevent Urinary Tract Infections And Restore Normal Bladder Function.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #6 Scope: Few
level Of Harm: 3
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #7 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Residents Receive Treatment/services To Not Only Continue, But Improve The Ability To Care For Themselves.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #8 Scope: Few
level Of Harm: 3
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #9 Scope: Few
level Of Harm: 3
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #10 Scope: Few
level Of Harm: 2
deficiency: Properly Care For Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, And Prostheses.
survey Date: 04/15/2009
date Of Correction: 05/08/2009 
Deficiency #11 Scope: Few
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 04/15/2009
date Of Correction: 05/08/2009 
Resident Assessment Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 1
deficiency: Provide Doctors Orders For The Resident's Immediate Care, At The Time The Resident Was Admitted.
survey Date: 04/15/2009
date Of Correction: 05/08/2009 
Administration Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 2
deficiency: Set Up An Ongoing Quality Assessment And Assurance Group To Review Quality Deficiencies Quarterly, And Develop Corrective Plans Of Action.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Pharmacy Service Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 06/22/2009
date Of Correction: 08/26/2009 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.
survey Date: 04/15/2009
date Of Correction: 05/08/2009 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 04/15/2009
date Of Correction: 05/08/2009 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
17 %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
32.95 %
Percent of long-stay residents who self-report moderate to severe pain
16.7 %
16.66 %
Percent of long-stay high-risk residents with pressure ulcers
5.8 %
12.58 %
Percent of long-stay residents who lose too much weight
3.7 %
11.83 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
14.6 %
15.63 %
Percent of long-stay residents with a urinary tract infection 8.1 / 8.8 % 
Percent of long-stay residents who have depressive symptoms
5.1 %
28.38 %
Percent of long-stay residents who were physically restrained
7.1 %
43.68 %
Percent of short-stay residents who self-report moderate to severe pain
35.5 %
25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
86.3 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
89.9 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
3.1 %
45.90 %
Percent of long-stay residents experiencing one or more falls with major injury
3.6 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
14.6 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
0.4 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain 23.8:1 % 
Percent of long-stay high-risk residents with pressure ulcers
6.7 %
9.22 %
Percent of long-stay residents who lose too much weight
4.7 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
65.9 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder 12.8:1 % 
Percent of long-stay residents with a urinary tract infection
13.4 %
9.58 %
Percent of long-stay residents who have depressive symptoms
6.1 %
19.86 %
Percent of long-stay residents who were physically restrained
6 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
3.1 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
39.9 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
87.7 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
87.8 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
2.8 %
17.34 %

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