Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fountain Hills Post Acute during CMS and state inspections, most recent first.
A resident with CHF, CKD, atrial fibrillation, and moderate dementia had a physician order for a regular diet with thin liquids and food cut into bite-sized pieces with large protein portions. This cut-up requirement was documented in the diet order and Menu Wizard tray card notes but was omitted from the care plan and not consistently recognized or implemented by nursing and CNA staff, some of whom believed it was only a preference. On a weekend breakfast, the resident was served an egg burrito that was only cut in half, and the CNA who delivered the tray did not recall reviewing the meal ticket or knowing of any need to cut food into bite-sized pieces. Later that morning, an LPN found the resident unresponsive in bed with mushy food in and around his mouth, initiated manual removal and suctioning, and, with the charge nurse, continued suction and use of a LifeVac device before EMS transport. Hospital records documented aspiration of eggs into the airway with respiratory failure, and the resident, who was DNR/DNI, subsequently died. The survey found that the facility failed to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and followed for this resident, and identified a similar failure for another resident whose diet orders were not properly implemented.
A cognitively intact resident with multiple medical conditions reported that an unknown male staff member inappropriately touched her breasts and genitals during the night prior to her hospital transfer. While hospitalized, the resident disclosed the alleged sexual assault to law enforcement, and a sheriff's deputy later informed facility staff that the resident had accused a tall Hispanic male of assault on the night of her fall, though he noted inconsistencies and altered mental status. Facility leadership, including the administrator/abuse coordinator and the DON, were aware of the concerns and of regulatory requirements and facility policy mandating that abuse allegations be reported to the state agency within two hours, but the allegation was not reported within the required timeframe.
A resident with PTSD and bipolar disorder was subjected to inappropriate behavior by a CNA during continence care, including unnecessary massaging and touching, which made the resident uncomfortable and affected her sleep. Another resident reported similar inappropriate behavior by the same CNA. The facility's DON confirmed that the CNA's actions were against the facility's policies, leading to the CNA's termination.
A resident did not receive their prescribed anti-seizure medication due to miscommunications and procedural lapses. The medication order was not sent to the pharmacy due to a missing electronic signature, and the facility's emergency kit did not have the medication. Staff were aware but did not take timely action to resolve the issue, leading to multiple missed doses.
A resident with mobility issues encountered a wet floor area without caution signs while walking with a physical therapist. Housekeeping staff admitted that caution signs were required but not available on the cleaning cart. Interviews with staff confirmed the facility's policy mandates caution signs to prevent accidents.
Failure to Follow Physician-Ordered Cut-Up Diet Leads to Fatal Aspiration Event
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician-ordered diet specifying that a resident’s food be cut into bite-sized pieces, and to ensure that this requirement was consistently communicated and implemented by nursing and dietary staff. Resident #9 had multiple diagnoses including heart failure, chronic atrial fibrillation, chronic kidney disease, and moderate vascular dementia with anxiety. A physician order dated December 23, 2024, prescribed a regular diet with regular texture, thin liquids, and explicitly directed that food be cut into bite-sized pieces with large protein portions. The facility’s nutrition care plan initiated on December 30, 2024, referenced the regular diet with large protein portions but did not include the requirement to cut food into bite-sized pieces. The cognition and ADL care plans addressed cognitive impairment and self-care deficits but did not incorporate the ordered cut-up diet or any specific swallowing precautions, despite the resident’s cognitive impairment and upper extremity limitations documented on the MDS. The dietary management and electronic systems in use contained the cut-up order, but this information was not reliably translated into practice. The Menu Wizard tray card history, as reviewed by the senior menu specialist, showed a diet order of regular, regular, thin liquids with notes to cut food into bite-sized pieces and provide large protein portions, and this instruction had been in place since December 23, 2024. The dietary manager stated that dietary staff are responsible for cutting food and that bite-sized pieces would include items like burritos, with food expected to arrive on the unit already cut. However, he also indicated he could not retrieve prior diet slips after discharge and relied on nursing to relay changes. The DON asserted that the “cut into bite-sized pieces” language was a preference rather than part of the actual diet order and stated that only the basic diet components (regular texture, thin liquids) transfer to the kitchen, while additional information such as cutting food does not cross over. In contrast, the prescribing physician confirmed that he ordered regular food, thin liquids, cut into bite-sized pieces, and large protein portions as a single diet order and expected the entire order, including cutting food into bite-sized pieces, to be followed. On the day of the choking event, breakfast trays were delivered to Resident #9’s room, and the resident was served an egg burrito, oatmeal, and cranberry juice. CNA staff reported that the burrito was cut in half but not further cut into bite-sized pieces, and CNA #6 stated she did not know the resident’s diet, did not recall reviewing the meal ticket, and believed his meals did not need to be cut up. She also stated she was unaware of any special instructions to cut the resident’s food into bite-sized pieces and that she typically relied on dietary and nursing to communicate such needs. Multiple CNAs and the charge nurse indicated they were not aware of any formal special diet instructions beyond a regular diet, although the charge nurse acknowledged knowing the family’s preference for cut-up food and finger foods and that dietary did not always cut up his meals, requiring nursing to do so. The resident’s family member reported repeated concerns to the dietary manager, charge nurse, DON, and CNAs about the resident’s food not being cut up, and stated that both she and a hired companion frequently found his meals served uncut despite his upper extremity weakness and motor decline. Later that morning, an LPN who had just started her shift and was not familiar with the resident found him in bed with his breakfast tray in front of him, food apparently eaten, and “mushy” food around and in his mouth. The resident appeared to be sleeping, did not respond to his name, and was grunting and moaning with snoring-type respirations. The LPN manually removed food from his mouth and began suctioning, and the charge nurse arrived with a suction machine and a LifeVac device. Staff observed egg on the resident’s chest and in his mouth, and suctioning removed egg and mucus secretions. EMS was called, and the resident was transported to the hospital. Hospital emergency department documentation recorded that the resident had been eating eggs, was later found choking and unresponsive, and presented with aspiration into the airway and respiratory failure with hypoxia and hypercapnia. The resident was documented as DNR/DNI and was ultimately pronounced deceased. The survey findings attribute this event to the facility’s failure to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and implemented by staff. The report also notes that for Resident #9 there were no active orders for PT/OT/ST evaluation or treatment on the Order Summary Report despite a NP/PA progress note planning for such services, and that the SLP evaluation focused on cognition and compensatory strategies rather than swallowing, with no active speech therapy orders in the diet context. Staff interviews revealed inconsistent understanding of the resident’s diet requirements, with some staff describing cut-up food and finger foods as a preference rather than an order, and others stating they had no knowledge of any special diet instructions. The grievance logs contained no formal grievances from the family member despite her statements that she had repeatedly complained about meals not being cut up and about the resident not being taken to the dining room as he preferred. Collectively, these documented actions and inactions show that the facility did not ensure the physician-ordered diet specifying cut-up, bite-sized food was integrated into the care plan, reliably communicated to dietary and direct care staff, or consistently implemented at the bedside for Resident #9, culminating in a choking and aspiration event requiring hospitalization and resulting in death.
Failure to Timely Report Allegation of Sexual Abuse to State Agency
Penalty
Summary
The facility failed to immediately report an allegation of sexual abuse to the administrator and the appropriate state agency within the required two-hour timeframe for abuse or serious bodily injury. The resident involved had diagnoses including metabolic encephalopathy, traumatic brain injury history, depression, anxiety disorder, and muscle weakness, and was documented as cognitively intact with a BIMS score of 15 on the most recent MDS. Nursing notes showed that the resident experienced altered mental status, slurred speech, and left-sided weakness and was transferred to the hospital. While hospitalized, the resident reported that during the night and early morning hours before transfer, an unknown male staff member had inappropriately touched her breasts and genitals. The resident stated she reported the incident to a sheriff's deputy after leaving the facility and being admitted to the hospital. The deputy later came to the facility, informed staff that the resident had alleged sexual assault by a tall Hispanic male on the night of her fall, and indicated that no further action was required due to the resident's altered mental status and inconsistencies in her account. Facility leadership, including the administrator/abuse coordinator and the DON, acknowledged awareness of concerns expressed by the resident after discharge and that law enforcement had contacted the facility. The administrator/abuse coordinator stated that regulations require reporting alleged abuse to the State Agency within two hours and recognized the risk of not reporting, while facility policy required allegations of abuse to be reported to appropriate state or federal agencies within required timeframes. Despite this, the allegation was not reported to the state agency as required.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect the right of a resident to be free from abuse by staff. Resident #10, who was admitted with diagnoses including post-traumatic stress disorder and bipolar disorder, required extensive assistance with daily activities and was cognitively intact. On February 27, 2024, a CNA (staff #13) provided continence care to Resident #10 and engaged in inappropriate behavior by massaging her neck, shoulders, and breasts, making the resident uncomfortable and affecting her sleep patterns. The resident reported the incident, and staff interviews confirmed the inappropriate actions of the CNA, who admitted to spending more time in the resident's room than necessary and using improper techniques during care. Another resident, #36, also reported that staff #13 attempted to massage her arms and was frequently present in their room without a clear purpose. The facility's Director of Nursing (DON) conducted interviews and confirmed that the CNA's actions were not in line with the facility's policies. The DON stated that while CNAs are trained to use massage to alleviate pain, it is not appropriate during continence care, and the resident should be clothed. The facility's policy on Freedom From Abuse, Neglect, Exploitation, revised in October 2023, emphasizes that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility's failure to adhere to its policies and procedures resulted in the abuse of Resident #10 by staff #13. The CNA's refusal to follow facility protocol and his inappropriate behavior during continence care led to his termination. The incident highlights the need for strict adherence to care protocols and the importance of protecting residents from abuse by staff members.
Failure to Administer Anti-Seizure Medication
Penalty
Summary
The facility failed to ensure a complete anti-seizure medication regimen was administered to a resident, resulting in a deficiency in medication administration. The resident, who was admitted with diagnoses including unspecified convulsions, had a prescribed regimen of Lacosamide and Lamotrigine. However, the Lacosamide was not administered from the time of admission due to a series of miscommunications and procedural lapses. The Medication Administration Record (MAR) showed that the Lacosamide order was not fulfilled, and the medication was not available in the facility's emergency kit or dispensing machine. Interviews with staff revealed that the medication order was entered into the facility's system but was not sent to the pharmacy due to a missing electronic signature. The Medical Director and nursing staff were aware of the issue but did not take timely action to resolve it. The Medical Director mentioned that the discharging facility was responsible for sending the electronic orders to the pharmacy, and there was a delay in obtaining the necessary signature. The resident reported not receiving the medication for three days, and the MAR confirmed multiple missed doses before the order was re-processed. The facility's policies on medication management and physician orders were not followed, leading to the resident not receiving the prescribed anti-seizure medication. Staff interviews indicated that there were opportunities to obtain the medication from alternative sources or to contact the pharmacy for an urgent delivery, but these steps were not taken. The deficiency highlights a breakdown in communication and adherence to established procedures, resulting in a lapse in the resident's care.
Failure to Use Caution Signs During Floor Cleaning
Penalty
Summary
The facility failed to ensure cautionary slippery-floor safety signs were present near a hazardous area for Resident #295. Resident #295, who was admitted with diagnoses including muscle weakness and abnormalities of gait and mobility, was observed walking with a physical therapist when they encountered a wet floor area outside a room. The liquid, identified as a cleaning solution, covered a significant portion of the hallway, and no cautionary slippery-floor safety signs were present. Housekeeping staff admitted that caution signs are always required but were not available on the cleaning cart being used at the time. Interviews with the physical therapist, maintenance supervisor, and director of nursing confirmed that the facility's policy mandates the use of caution signs when mopping floors. The physical therapist expressed concern about the safety of residents walking near wet areas, and the maintenance supervisor and director of nursing reiterated the expectation that caution signs should be in place to prevent accidents. The facility's policy on fall management emphasizes the importance of maintaining an environment free of accident hazards and providing appropriate interventions to prevent falls.
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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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