Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Prescott Village Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to obtain and document informed consent for psychotropic and opioid medications for three residents. Two cognitively intact residents received opioids and psychotropics, including tramadol, oxycodone, trazodone, and Dilaudid, without signed, medication-specific consents, and the opioid consent forms used did not list the drug names. Another resident with severe cognitive impairment was given multiple psychotropic medications, including alprazolam, paroxetine, mirtazapine, and risperidone, but consent was only documented for some of these drugs. Staff reported that they assume an order in the EHR means consent has been obtained and do not routinely verify consents before administering these medications, despite a policy requiring informed consent prior to administration.
The facility failed to ensure PRN pain medications were administered within physician-ordered pain scale parameters for three cognitively intact residents with multiple comorbidities, including diabetes, dementia, joint replacement aftercare, encephalopathy, respiratory failure, and acute kidney failure. MAR reviews showed acetaminophen, tramadol, and oxycodone were repeatedly given for pain ratings outside the ordered ranges over several months. During interviews, an LPN, the ADON, and the interim DON each confirmed that medications had been administered outside the prescribed parameters and described associated risks such as overdose, unnecessary sedation, over-sedation, lethargy, respiratory distress, constipation, and residents not being able to get ahead of their pain. The facility’s Medication Administration policy lacked specific language on following physician-ordered pain parameters, despite requiring review of the MAR and three checks against the physician’s order, pharmacy label, and MAR.
The facility failed to ensure that a licensed pharmacist completed and documented required monthly medication regimen reviews for several residents with complex conditions and multiple medications, including psychotropics, opioids, anticonvulsants, antibiotics, diuretics, and hypoglycemics. Record review showed multiple consecutive months without documented pharmacist reviews for four residents, with only occasional single-month reviews noted and no recommendations recorded. The ADON reported that medication reviews are done on admission and that monthly pharmacist packets are reviewed by him and the provider, but he confirmed that pharmacy review records for numerous months could not be located and acknowledged this was not acceptable. The interim DON stated the pharmacist visits monthly but believed reviews were only required quarterly, despite the facility’s policy specifying that each resident’s medication regimen must be reviewed at least monthly and documented in the medical record.
Surveyors found that dietary staff did not consistently follow sanitation and food storage standards. A cook was observed preparing vegetables without a required beard net, despite facility policy and staff statements that hairnets and beard guards must be worn upon entering the kitchen to prevent hair from contaminating food. Inspectors also found expired food items, including pickled beets and processed Swiss cheese, stored in the refrigerator past their labeled use-by dates. Dietary staff, including the Director of Nutritional Services, confirmed they are responsible for labeling and checking food twice weekly and that food must be discarded by the use-by date to prevent foodborne illness, acknowledging that the observed practices did not meet facility expectations.
The facility failed to ensure that direct care staffing information submitted to CMS via PBJ was complete and accurate, as PBJ reports showed repeated excessively low weekend staffing and a one-star staffing rating while the facility’s own assessment documented higher daily nurse and CNA coverage. When surveyors requested detailed staffing submission data, the administrator could not promptly provide it, and a PBJ validation report showed that Total Employee Link Records were not submitted. Multiple residents reported long delays in call light response and assistance, including waits of 30–90 minutes, and one resident noted a nurse working six consecutive days due to open shifts. A CNA described working with only one other CNA in the building when others called off, and an LVN reported frequent staffing issues and difficulty finding replacements amid high turnover. The administrator stated that staffing was planned to meet state minimums, relied on a vendor to transmit timeclock data to CMS, did not personally review PBJ submissions, and was unaware of staffing triggers or low staffing star ratings, despite a policy requiring accurate daily submission of all direct care staffing, including agency and contract staff.
A resident with significant neurological, renal, and mental health diagnoses, and severely impaired decision-making at discharge, was sent home with a family member without a documented physician order authorizing discharge and without discharge goals or objectives in the care plan. An undated discharge planning form cited insurance as the reason for discharge and noted there would be no caregiver or home services in place. Review of the EHR showed no discharge order in the physician order tab, and a verbal discharge order with home health services was only entered months later at the direction of leadership. The ADON, Interim DON, and an LPN all acknowledged that a physician order is required for discharge and that such orders should appear in the EHR, while facility policy specifies that transfers and discharges occur only upon a physician’s order with supporting clinical documentation.
A resident with multiple chronic conditions and intact cognition signed a Prehospital Medical Care Directive refusing all resuscitation measures, and a practitioner note documented the resident as DNR. However, the EHR landing page listed the resident as full code, there was no DNR physician order, and the care plan identified the resident as full code with CPR to be initiated. On the unit, the Advanced Directives Book contained the resident’s DNR form, but the cover sheet still labeled the resident as full code. An RN, the interim DON, and a CNA all confirmed reliance on these records for code status and acknowledged that the documentation was inconsistent, contrary to facility policies requiring accurate, complete physician orders and honoring advance directives.
A resident with documented generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, and use of aripiprazole for behavior management was admitted with a hospital PASRR that showed no serious mental illness or mental illness. Despite multiple layers of review by admissions, social services, MDS, and corporate auditing, staff did not identify or correct the inaccurate Level I PASRR on admission, even though the facility’s policy requires a complete Level I PASRR screening for all first-time applicants before admission or on the first day Medicaid reimbursement is requested.
A resident with generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, muscle weakness, morbid obesity, and bariatric surgery status, and a BIMS score indicating cognitive intactness, remained in the facility for more than 30 days while receiving aripiprazole for PTSD and bipolar disorder. The only PASARR in the record was the hospital preadmission PASARR, which was null for serious mental illness and mental illness, and no new Level I PASARR was completed within 40 days as required by facility policy. Staff interviews showed that the social services clerk did not handle PASARRs, the regional LMSW reported the facility had only recently obtained information to submit PASARRs and that incorrect hospital PASARRs should be corrected, the MDS nurse relied on social services for PASARR review and did not check for Level II PASARRs, and the admissions coordinator stated that PASARRs are reviewed before admission by intake and a corporate auditor, yet no updated PASARR was present for this resident.
A resident with multiple serious medical conditions, intact cognition, and documented ADL deficits requiring assistance with personal hygiene was observed with yellow, brittle toenails extending several centimeters beyond the toes and a jagged fingernail, despite being unable to perform self-care. The EHR, shower sheets, and skin checks contained no documentation that nail issues had been identified or that nail care had been provided, and there was no evidence of podiatry involvement. A CNA and an LVN described that CNA staff are responsible for routine nail care and documentation, with podiatry used for certain residents, while the RN confirmed that excessively long nails should have been identified during weekly skin checks. Review of records and staff interviews showed that required nail care and documentation, as outlined in facility policy, were not carried out for this resident.
A resident with moderate cognitive impairment and multiple medical conditions was found with various treatment items and medications left on an overbed table at the bedside, including Medihoney wound treatment, skin protectant, a wound cleanser, and a bottle of mineral oil labeled as a lubricant laxative. Nursing staff acknowledged that medications and treatment supplies should not be left at the bedside and were unclear about which items qualified as medications. The DON confirmed that medications, including mineral oil, are not to be stored at the bedside without a completed self-administration assessment and proper documentation, and facility policies required secure storage of medications and prohibited bedside storage without documented interdisciplinary assessment, which was not present for this resident.
A resident with severe cognitive impairment and multiple comorbidities, including acute kidney failure and a UTI, had an indwelling Foley catheter with orders for enhanced barrier precautions and routine catheter care. During ambulation with assistance from a PTA, the resident’s catheter drainage bag was observed hanging below the wheelchair and dragging on the floor, and this continued as the resident walked with the wheelchair behind. A RN, the interim DON, and a CNA all stated that catheter bags are expected to be secured, covered, and never allowed to touch the floor due to infection control concerns. The facility’s catheter care policy also specifies that the collection bag must not touch the floor at any time, but this requirement was not followed in this incident.
A deficiency was cited when a resident's care plan did not address all assessed needs and failed to include measurable timetables and specific actions, as observed in the care planning documentation.
A resident with severe cognitive impairment and a history of wandering eloped from the facility despite having a wanderguard in place, as the front door alarm was not functioning. Staff were unaware of the resident's departure until notified by an outside party, and interviews confirmed that required monitoring procedures were not effectively carried out.
A resident with a history of fractures and mobility deficits was injured during a hoyer lift transfer when two CNAs, including an agency staff member unfamiliar with the resident, used the wrong type and size of sling and failed to remove a leg strap securing the resident to the wheelchair. The improper transfer caused acute pain and resulted in a right distal femur fracture, as confirmed by x-ray and hospital evaluation. Staff did not follow established procedures for safe transfers or ensure the correct equipment was used.
A resident with multiple health issues suffered a leg injury during a hoyer lift transfer when her leg remained strapped to the wheelchair, causing significant pain. Although CNAs notified the nurse and pain medication was given, there was no timely assessment, incident report, or notification to the physician or family as required by policy. The resident's pain worsened, and only the next day was the physician notified and x-rays ordered, which later revealed a femur fracture. Required documentation and notifications were delayed, contrary to facility policy.
A resident experienced an injury during a hoyer lift transfer, but the facility failed to document the incident, assessments, and notifications in a timely and complete manner, resulting in incomplete medical records. Additionally, the facility did not provide requested therapy documentation for another resident within the expected timeframe, and staff qualification records for a contracted CNA were not readily available, causing delays during the survey process.
The facility failed to ensure that dishes and utensils were cleaned under sanitary conditions, with inconsistent dishwasher temperature readings and improper documentation by the senior cook. The Administrator confirmed the issue and the expectation for proper logging of temperatures.
The facility failed to provide timely written transfer/discharge notices to three residents, including one with severe cognitive impairment and another who was cognitively intact. The facility's practice of verbal notification in emergencies contradicted its policy, leading to potential unsafe discharges.
The facility failed to assess and administer pain medications according to accepted standards for two residents. One resident with severe cognitive impairment and another who is cognitively intact had inconsistencies in their pain medication administration, with some medications not being administered and others given without a specified pain scale. Interviews revealed a discrepancy in understanding pain scale requirements for PRN medications.
The facility failed to ensure that a pharmacy medication recommendation for a resident on anticonvulsant therapy was reviewed and implemented. The resident's valproic acid levels were not monitored as recommended, and interviews revealed a lack of clear responsibility for following up on pharmacy recommendations.
The facility failed to ensure that a resident's clinical record included the required information for transfer/discharge. A resident with severe cognitive impairment and multiple diagnoses was discharged to a medical center due to shortness of breath, but no discharge summary was found in the clinical record. The DON acknowledged the absence, and the Administrator was unsure of the discharge policy.
The facility failed to revise care plans for two residents following falls, resulting in delayed or missing interventions. Staff interviews confirmed that the expected protocol for falls was not followed, and the Administrator acknowledged the delay in updating care plans.
Failure to Obtain and Document Informed Consent for Psychotropic and Opioid Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic and opioid medications for multiple residents, despite a policy requiring such consent before administration. For one cognitively intact resident with dementia, diabetes, dysphagia, and acute kidney failure, the MDS showed use of antidepressant and opioid medications. Physician orders included PRN tramadol and oxycodone for pain and PRN trazodone for insomnia. Review of the electronic health record did not show signed consents for tramadol, oxycodone, or trazodone. An opioid consent form in the record had an effective date but did not identify the specific opioid medications. Medication administration records showed that tramadol and oxycodone were administered numerous times over several months without documented, medication-specific informed consent. Another resident with severe cognitive impairment, Alzheimer’s disease, dementia, dysphagia, and a cognitive communication deficit was receiving multiple psychotropic medications, including alprazolam, paroxetine, mirtazapine (Remeron), and risperidone. The facility produced signed consent forms for paroxetine, mirtazapine, and risperidone, but there was no documented consent for alprazolam, despite an active order for chronic anxiety. The orders for these medications had been in place and updated over an extended period, indicating ongoing use without complete corresponding consents for all psychotropic agents. A third cognitively intact resident with traumatic ischemia of muscle, opioid dependence with opioid-induced sleep disorder, chronic respiratory failure with hypoxia, and knee pain had an order for scheduled oral Dilaudid three times daily for pain. The EHR did not contain a signed consent specific to Dilaudid. An opioid consent form in the record had an effective date but did not list the name of the opioid medication. Staff interviews confirmed that nurses rely on the presence of orders in the EHR as an indication that consents have been obtained and do not routinely verify consent before administering psychotropic or opioid medications. The ADON and regional nurse acknowledged that consents are required, that forms in use did not include medication names, and that an opioid consent form had been created in-house without a field for the specific drug name, contributing to the lack of medication-specific informed consent documentation.
Failure to Administer PRN Pain Medications Within Ordered Pain Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure that PRN pain medications were administered within the physician-ordered pain scale parameters for three residents. For one resident with type 2 diabetes, dysphagia, dementia, acute kidney failure, and a cognitive communication deficit, the MDS showed she was cognitively intact and receiving antidepressant and opioid medications. Pharmacy review in December 2025 specifically requested that nursing staff be reminded that pain medications must be given within parameters. Despite this, review of the MARs showed acetaminophen and tramadol were repeatedly administered outside the ordered pain scale ranges across multiple months, including June, November, December, January, and February. Another cognitively intact resident with aftercare following joint replacement surgery, dysphagia, cognitive communication deficit, and acute kidney failure had an order for acetaminophen 325 mg, two tablets every six hours PRN for generalized or breakthrough pain rated 1–4. The February MAR showed acetaminophen was administered outside of these parameters on three separate dates. This resident’s care plan, initiated in September 2025, identified a need for pain management related to right hip pain and included an intervention to administer analgesia per physician’s orders, yet the MAR documentation demonstrated that the ordered parameters were not consistently followed. A third cognitively intact resident with encephalopathy, acute and chronic respiratory failure, and acute kidney failure had an order for oxycodone 10 mg every four hours PRN for pain rated 6–10. The February MAR showed oxycodone was administered once when the resident rated pain as 3, which was outside the ordered parameters. During interviews, an LPN, the ADON, and the interim DON each reviewed the MARs and acknowledged that acetaminophen, tramadol, and oxycodone had been administered outside the prescribed pain parameters, and they described risks such as overdose, unnecessary sedation, over-sedation, lethargy, respiratory distress, constipation, and residents not being able to get ahead of their pain. Review of the facility’s undated Medication Administration policy showed it did not contain language about administering medications according to physician-established pain parameters, although it did reference reviewing the MAR for special considerations and conducting three checks against the physician’s order, pharmacy label, and MAR.
Failure to Ensure Monthly Pharmacist Medication Regimen Reviews for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly medication regimen reviews (MRRs) for multiple residents, as required by facility policy. The facility’s written Drug Regimen Review policy, revised in January 2025, states that the pharmacist will review each resident’s medication regimen at least monthly to detect irregularities and clinically significant risks, and will document in the resident’s medical record that the review has been completed. Surveyors’ review of pharmacy review documents, closed records, and staff interviews showed that these monthly reviews were missing for several residents over multiple months. For one resident with aftercare following joint replacement surgery, dysphagia, cognitive communication deficit, and acute kidney failure, who was cognitively intact and receiving antidepressant, opioid, and anticonvulsant medications, there were no documented pharmacy reviews for October and November 2025, and January and February 2026; only a December 2025 review was present with no recommendations. Another resident with Alzheimer’s disease, dysphagia, dementia, and cognitive communication deficit, who had severe cognitive impairment and was receiving antipsychotic, antianxiety, antidepressant, antibiotic, diuretic, and hypoglycemic medications, had no documented pharmacy reviews for September, October, and November 2025, and January and February 2026, with only a December 2025 review available showing no recommendations. A third resident with traumatic ischemia of muscle, opioid dependence with opioid-induced sleep disorder, chronic respiratory failure with hypoxia, and left knee pain, who was cognitively intact and receiving antidepressant and opioid medications, had no documented pharmacy reviews for August, September, October, and November 2025, and January and February 2026. A fourth resident with type 2 diabetes, dysphagia, unspecified dementia, acute kidney failure, and cognitive communication deficit, who was cognitively intact and receiving antidepressant and opioid medications, had no documented pharmacy reviews for September, October, November, and December 2025, and January and February 2026. During interviews, the ADON stated that medication reviews are conducted upon admission with the facility provider and that the facility receives a monthly packet from the pharmacist, which he and the provider review, sometimes with pharmacist suggestions that may or may not be accepted, and then sent to medical records. However, he confirmed that he could not locate the pharmacy review records for the missing months for the identified residents and acknowledged that not having monthly pharmacy reviews was not acceptable. The interim DON reported that the pharmacist is in the facility monthly but believed pharmacy reviews only needed to be conducted quarterly, which conflicted with the facility’s written policy requiring at least monthly reviews and documentation in the medical record.
Improper Hair Restraint Use and Storage of Expired Food in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in the facility’s food service operations related to improper use of hair restraints and failure to discard expired food items. During an initial kitchen observation, a cook was seen preparing vegetables at the food preparation counter without a beard net, despite having a beard. Multiple staff interviews, including with another cook and the Director of Nutritional Services, confirmed that facility policy requires hairnets and beard guards to be worn upon entering the kitchen to prevent hair from falling into food or onto plates. The facility’s written Kitchen Sanitation policy, last revised January 1, 2025, also states that all kitchen staff must wear hairnets and beard guards when needed. Surveyors also observed expired food items stored in the kitchen refrigerator. A container of pickled beets with a use-by date of February 27, 2026 was found on the third shelf of the refrigerator during the initial observation. On a subsequent observation, a gallon-sized ziplock bag containing several partial blocks of pasteurized processed white Swiss cheese was found with a received date of February 23, 2026 and a use-by date of March 3, 2026, but it had not been discarded. Staff interviews revealed that cooks and the Director of Nutritional Services are responsible for checking food dates twice weekly and labeling food with received and use-by dates, and that food is not to be served past the use-by date. When shown the expired cheese, a cook acknowledged it should have been discarded and stated that expired food could cause residents to get sick. Another cook and the Director of Nutritional Services similarly stated that food not discarded by the discard date could cause a potential outbreak and foodborne illness, and both acknowledged that the observed situations did not meet expectations or policy requirements.
Inaccurate PBJ Staffing Data Submission and Reported Delays in Resident Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure that direct care staffing information submitted to CMS through the Payroll-Based Journal (PBJ) system was complete and accurate, based on verifiable and auditable data. PBJ reports showed the facility consistently triggered for excessively low weekend staffing for three quarters and received a one-star staffing rating for two fiscal quarters. The facility assessment documented a licensed capacity of 58 residents with a current census of 50 and indicated daily nursing staffing of three nurses on day shift and two on night shift, with an RN present at least 8 consecutive hours per day and three CNAs on night shift and four on day shift. However, when surveyors requested detailed staffing submission data, the administrator stated that timeclock data went to a vendor (Xchieve) which then submitted to CMS, and that the information was located out of state and not immediately available. Review of the PBJ submitter final file validation report obtained from the facility showed that the Total Employee Link Records portion failed to be submitted. Resident and staff interviews and facility documentation further demonstrated discrepancies and concerns related to staffing. Multiple alert and oriented residents reported long waits for assistance, including call lights taking 30–60 minutes or up to 1.5 hours to be answered, and one resident reporting that a nurse worked six days in a row due to open shifts. Another resident reported the facility felt understaffed with CNAs, especially on day shift. A CNA reported having to work with only one other CNA in the building when others called off, and an LVN stated that staffing was an issue when staff called out and that finding replacements was difficult, with significant staff turnover in the prior six months. The administrator stated that staffing expectations were to meet state minimums, that direct care staff included CNAs, LPNs, RNs, and therapy, and that all staff clocked in and out with data sent to the vendor, but the administrator did not review PBJ data after submission, was unaware of staffing triggers or low staffing star ratings, and could not state the nursing turnover rate. The facility’s staffing policy required submission of daily direct care staffing information, including agency and contract staff, to the CMS PBJ system and directed staffing inquiries to the administrator or designee, but the incomplete PBJ submission and lack of administrative oversight led to inaccurate staffing information being reported.
Failure to Obtain and Document Physician Order Prior to Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a physician’s order prior to discharging a resident. The resident was admitted with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side, dysphagia, acute kidney failure, and major depressive disorder. On admission, staff assessed the resident’s cognitive skills for daily decision making as moderately impaired, and at discharge they were assessed as severely impaired. Progress notes documented that the resident was discharged home with a family member, but the physician’s orders did not contain an order authorizing discharge, and the resident’s care plan did not include discharge goals or objectives. A Discharge Planning Review form, which was undated, indicated the resident was discharged home due to insurance, noted that the resident would not have a caregiver after discharge, and that no home services were in place. Surveyor review of the EHR did not show a discharge order in the physician’s order list or order tab. A physician’s order for discharge with home health services, dated as a verbal order on the day of discharge, was not entered into the EHR until months later, with a printed date corresponding to the survey. The ADON stated that residents who discharge require a discharge summary, physician’s orders indicating the resident is able to discharge, and a recapitulation of the stay, and acknowledged being asked by the Interim DON to enter the discharge order on the survey date, while being unsure whether the physician had actually given an order at the time of discharge. The Interim DON reported that a physician’s order was received the day of discharge but confirmed it was only entered into the EHR on the survey date. An LPN stated that everything related to a resident, including discharge, requires a physician’s order and that the order tab is the only place in the system where such orders can be found, and confirmed that the discharge order for this resident was created the day before his interview. The facility’s Transfer and Discharge policy, last revised in June 2020, states that residents are transferred or discharged upon a physician’s order and that the clinical record must contain physician documentation supporting the necessity of the transfer or discharge.
Inconsistent Documentation of DNR Status and Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent documentation of a resident’s code status and advance directives across the medical record and unit reference materials. A cognitively intact resident, as evidenced by a BIMS score of 14 on the admission MDS, had multiple serious diagnoses including hypertension, osteomyelitis, anemia, MRSA infection, rheumatoid arthritis, chronic kidney disease, type 2 diabetes with neuropathy, muscle wasting, muscle weakness, and gait abnormalities. The resident signed a Prehospital Medical Care Directive indicating refusal of all resuscitation measures in the event of cardiac or respiratory arrest, including chest compressions, intubation, artificial ventilation, defibrillation, ACLS drugs, and related emergency procedures. Despite this signed directive, the electronic health record (EHR) landing page listed the resident as a full code, and there was no corresponding DNR physician order in the orders section. A practitioner progress note documented the resident’s code status as DNR on the same date as the directive, but this was not translated into an active order. The care plan further reflected a full-code CPR focus, with a goal that CPR be initiated and followed, and interventions referencing ensuring proper documents were signed and counseling the resident and family, thereby conflicting with the signed DNR directive and practitioner note. On the unit, the Advanced Directives Book contained the resident’s orange DNR form, but the cover sheet listing resident names identified the resident as a full code, creating additional inconsistency. During interviews, an RN stated she would rely on the Advanced Directives Book to determine code status during an emergency and confirmed the discrepancy between the book’s cover sheet and the DNR form, as well as the EHR landing page showing full code. The interim DON confirmed that the EHR landing page pulls from physician orders, acknowledged there was no DNR order and no care plan reflecting DNR status, and stated that documentation needs to match so everyone is on the same page. A CNA also stated that advanced directives are documented in the EHR and in a binder for DNR residents and emphasized that all documentation must be accurate so staff know how to act. Facility policies on Advanced Directives and Physician Orders required honoring residents’ directives and ensuring orders are complete and accurate, but these expectations were not met for this resident.
Failure to Ensure Accurate Level I PASRR for Resident With Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure a complete and accurate Level I PASRR assessment on admission for one resident. The resident was admitted with diagnoses including generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, muscle weakness, morbid obesity, and bariatric surgery status, and had a BIMS score of 15 indicating intact cognition. The resident’s care plan documented use of the psychotropic medication aripiprazole for PTSD and bipolar disorder, initiated and revised in late January 2026. However, the PASRR received from the hospital indicated “null” for serious mental illness and mental illness, meaning no psychiatric diagnoses were identified at the hospital level, despite the resident’s documented psychiatric conditions. During interviews, the social services clerk reported working on discharge planning from the beginning of admission but stated she did not handle PASRRs. A regional LMSW explained that the facility had recently obtained the ability to submit PASRRs electronically and stated that incorrect hospital PASRR data should be corrected immediately, acknowledging that the resident’s psychiatric diagnoses should have been identified and reviewed to determine if a Level II PASRR was needed. The MDS nurse stated he was told social services reviewed PASRRs and therefore did not check whether residents had a Level II, and that he had never seen a Level II from the hospital. The admissions coordinator reported that PASRRs are reviewed prior to accepting a resident by herself, central intake, and a corporate auditor, and that the Level I PASRR is usually the last document sent before admission. Despite this, the inaccurate Level I PASRR for this resident was not corrected on admission, contrary to the facility’s PASRR policy requiring Level I screening for all first-time applicants before admission or on the first day Medicaid reimbursement is requested.
Failure to Complete Required Level I PASARR for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a new Level I PASARR was completed within the required timeframe for a resident who remained in the facility for more than 30 days. The resident was admitted with diagnoses including generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, muscle weakness, morbid obesity, and bariatric surgery status, and had a BIMS score of 15, indicating cognitive intactness. The care plan documented that the resident was receiving the psychotropic medication aripiprazole for PTSD and bipolar disorder, initiated and revised in late January 2026. The only PASRR available in the record was the preadmission PASRR from the hospital, which was null for serious mental illness and mental illness, and there was no evidence of a second Level I PASARR being completed after the resident had been in the facility for more than 30 days. Interviews with staff revealed gaps in responsibility and process for PASARR completion and review. The social services clerk reported working on discharge planning from admission and stated she did not handle PASARRs, while the regional LMSW explained that the facility had only recently received information to be able to submit PASARRs and that incorrect hospital PASRR data should be corrected immediately; however, no corrected PASRR was found for this resident. The MDS nurse stated he was told that social services reviewed PASARRs, that he did not check for Level II PASARRs, and that he had never seen a Level II from the hospital, acknowledging that an inaccurate Level I on admission could affect needed services. The admissions coordinator reported that PASARRs are reviewed prior to accepting a resident by herself and the central intake team, and that a corporate auditor reviews the PASARR and admission information. The facility’s PASRR policy stated that if a facility stay is longer than 30 days, a Level I screening must be performed within 40 days of admission, which was not done for this resident.
Failure to Provide and Document Necessary Nail Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide basic nail care and assistance with activities of daily living for a resident who was unable to perform this care independently. The resident was admitted with multiple significant diagnoses, including sequelae of cerebral infarction, systolic heart failure, anemia, acute kidney failure, acute respiratory failure with hypoxia, osteoporosis, major muscle wasting and atrophy, muscle weakness, dysphagia, gait and mobility abnormalities, cognitive communication deficit, need for assistance with personal care, and neuromuscular bladder dysfunction. A 5-day MDS showed the resident was cognitively intact with a BIMS score of 14, had no psychosis or behaviors, but had upper extremity impairment on both sides and lower extremity impairment on one side. The care plan documented significant ADL deficits and indicated the resident required caregiver assistance with personal hygiene/oral care and extensive assistance for repositioning and turning in bed. Despite these documented needs, the EHR contained no evidence that the resident’s finger or toenail issues had been identified, nor that the nails had been trimmed or cleaned. During an observation, the resident was seen in bed with left toenails that were yellowish, brittle, and extending a few centimeters above the tip of the toes, while the right foot had an orthopedic boot and a wound dressing was present on the left foot. In a subsequent observation, the resident’s left thumb nail was jagged, and the right hand had contractures, with no indication that the toenails had been trimmed since the prior day. The resident reported that her toenails had not been cut for several months. Interviews with staff revealed inconsistencies between facility expectations and actual practice and documentation. A CNA stated that nail care is performed during showers and documented on shower sheets, and that CNA staff trim nails that are jagged or extend more than 1/4 inch, with podiatry involved for some diabetic residents’ toenails. An LVN stated that CNA staff provide fingernail care for non-diabetic residents and that nail care documentation should be in the EHR, with podiatry responsible for toenail care. Upon direct observation of the resident, both the LVN and the assigned RN acknowledged that the resident’s fingernails and toenails were excessively long and should have been clipped, and the RN stated that such issues should be identified during weekly skin checks and had not been identified by either CNA staff or nursing. Review of shower sheets and skin checks showed no documentation of excessively long nails, podiatry involvement, or nail care, despite a facility policy requiring CNA staff to trim and document nail care unless specific conditions such as diabetes, circulatory impairment, or problematic nails were present.
Medications and Treatments Improperly Left at Bedside
Penalty
Summary
Surveyors identified a deficiency related to improper storage of medications and treatments at the bedside for Resident #46. The resident was admitted with diagnoses including left hand contracture, dysphagia, major depressive disorder, and muscle weakness, and had a BIMS score of 10 indicating moderate cognitive impairment. The care plan contained no documentation authorizing medications at the bedside. During an observation in the resident’s room, surveyors noted an overbed table covered with a disposable bed pad holding multiple items, including a clear resealable bag with gauze, an abdominal pad package, bandages, an opened 200-count package of 4x4 gauze sponges, three individually wrapped oral swabs, a silver wound dressing package, a small black tube with a white cap, an opened skin protectant packet, a spray bottle of Skintegrity wound cleanser, and a nearly full 16-ounce bottle of mineral oil labeled as a lubricant laxative. In interviews, an RN identified the black tube as Medihoney used for wound treatment and acknowledged that it, along with the skin protectant, should not be kept at the bedside, and was unsure whether the wound cleanser could remain in the room or if mineral oil was considered a medication. A CNA stated that no medications or treatment supplies are allowed to be left at the bedside. The regional interim DON confirmed that medications are not to be left at the bedside unless a self-administration assessment is completed, the physician is contacted, and the appropriate form is completed and signed, and further clarified that medications are anything administered to residents, including mineral oil. The DON was only aware of the wound cleanser being at the bedside and not the mineral oil, Medihoney, or skin protectant. Facility policies on Medication Storage, Medication Administration, and Self-Administration of Medications all required secure storage of medications, prohibited leaving medications at the bedside, and required documentation of interdisciplinary assessment and determination regarding bedside storage in the medical record and care plan, which had not been done for this resident.
Failure to Maintain Catheter Bag Off the Floor During Resident Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control standards for the management of an indwelling urinary catheter for Resident #27. The resident was re-admitted with multiple diagnoses including chronic kidney disease, acute kidney failure, urinary tract infection, infection and inflammatory reaction due to other urinary catheter, obstructive and reflux uropathy, and pneumonia, and had a BIMS score of 7 indicating severe cognitive impairment. Physician orders documented enhanced barrier precautions due to a Foley catheter, catheter care every shift and as needed, and weekly changes of the catheter securement device. The care plan directed staff to position the catheter bag and tubing below the level of the bladder, away from the entrance room door, to check tubing for kinks, and to keep the drainage bag off the floor. On the survey date, the resident was observed in the hallway seated in a wheelchair and being assisted with ambulation by a PTA, with the catheter bag hanging below the wheelchair and dragging on the floor. The PTA then assisted the resident to stand and walk with the wheelchair behind, while the catheter bag continued to trail on the floor. A RN, when the issue was pointed out, stated that the bag should never touch the floor under any circumstances due to infection control concerns and adjusted the bag once the resident was seated in the dining area. The PTA acknowledged that the bag had been touching the floor and stated it should not have been. The interim DON and a CNA both stated that catheter bags are expected to be secured, hanging from the bed or wheelchair, covered with a privacy cover, properly anchored, and never allowed to touch the floor, citing infection control concerns and risk of rupture or the bag popping open. The facility’s catheter care policy, last reviewed in January 2025, specified that the collection bag must not touch the floor at any time, which was not followed in this instance.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where it was found that the care plan did not comprehensively cover the resident's assessed needs or include clear, measurable objectives and interventions.
Failure to Prevent Resident Elopement Due to Inoperative Door Alarm
Penalty
Summary
A resident with a history of dementia, disorientation, and a recent fracture was admitted to the facility and assessed as a moderate elopement risk upon admission. The resident's cognitive status declined over time, as indicated by a drop in the BIMS score from 10 to 3, reflecting severe cognitive impairment. Physician orders were in place for a wanderguard device due to the risk of elopement, and staff were instructed to monitor the device's function. Despite these measures, the resident was last seen at the nurses station and was later found at a nearby emergency room, having left the facility without staff knowledge. Staff interviews confirmed that the wanderguard was in place at the time of the incident, but the front door alarm was not functioning, allowing the resident to exit undetected. Staff reported that residents at risk for elopement are typically monitored with wanderguards and that door alarms are expected to alert staff if such residents approach exits. However, on the day of the incident, the malfunctioning front door alarm failed to activate, and the resident was able to leave the premises. The deficiency was further evidenced by staff statements acknowledging the resident's increased elopement risk following improved mobility and the lack of immediate staff awareness of the resident's departure. Facility policy required reinforcement of procedures for residents at risk of elopement, but these procedures were not effectively implemented in this case.
Failure to Ensure Safe Hoyer Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide safe assistance to a resident during a mechanical hoyer lift transfer, resulting in an injury. The resident, who had a history of multiple fractures, an open wound on the right foot, epilepsy, and a disorder of bone density and structure, required a mechanical lift for all transfers due to an activity of daily living self-care deficit. On the day of the incident, two CNAs attempted to transfer the resident from her wheelchair to her bed using a hoyer lift. The resident's leg was still strapped to the wheelchair during the lift, and the wrong type and size of sling was used. The resident immediately complained of pain, and the transfer was halted, but the resident sustained a fracture to the right distal femur as confirmed by subsequent x-rays and hospital evaluation. Multiple staff interviews and witness statements revealed that the CNAs involved were not familiar with the resident's specific needs and did not ensure the correct sling was used or that all straps were removed prior to the transfer. One CNA was an agency staff member unfamiliar with the resident, and the other was not experienced with the resident's care. The resident's usual sling was missing, and the staff used a different type of sling, which was not appropriate for the resident's condition. The improper placement of the sling and failure to unstrap the resident's leg from the wheelchair leg rest led to the resident experiencing acute pain and ultimately a femur fracture. Facility documentation and policy review indicated that staff did not follow established procedures for assessing the resident's needs, choosing the correct sling, and ensuring all safety measures were in place before performing the transfer. The incident was not immediately recognized as a significant injury, and there was a delay in notifying the physician and obtaining diagnostic imaging. The lack of adherence to safe transfer protocols and insufficient staff familiarity with the resident's care requirements directly contributed to the accident and resulting injury.
Failure to Timely Assess, Document, and Notify After Resident Injury
Penalty
Summary
A resident with multiple medical conditions, including an open wound, pelvic fractures, and a history of bone disorders, experienced an incident during a hoyer lift transfer. During the transfer, the resident's leg remained strapped to the wheelchair, resulting in immediate pain and distress. Although the CNAs involved notified the nurse within five minutes and Tylenol was administered, there was no documented assessment, incident report, or notification to the physician or the resident's family on the day of the incident. The resident's pain escalated throughout the day, requiring stronger pain medication, but still no communication with the provider was documented at that time. The following day, the resident continued to experience significant pain, prompting further assessment and eventual notification of the physician, who ordered x-rays. The x-rays, completed the next day, revealed a distal femur fracture, and the resident was subsequently sent to the emergency room for further evaluation and treatment. Documentation showed that the required change of condition evaluation was not completed until several days after the incident, and the incident report was also delayed. Interviews with staff confirmed that the incident was not reported or documented according to facility policy on the day it occurred. Facility policies required immediate assessment, documentation, and notification to the physician and family following incidents resulting in injury or significant change in condition. However, the clinical record review, staff interviews, and policy review revealed that these steps were not followed. The lack of timely assessment, documentation, and notification could have resulted in delayed care and lack of awareness by the physician and family regarding the resident's condition.
Incomplete Medical Records and Delayed Documentation Provision
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced an incident during a hoyer lift transfer. The resident, who had multiple medical conditions including an open wound, pelvic fractures, hypothyroidism, epilepsy, and bone disorders, was involved in a transfer incident where the hoyer lift sling was not properly used, resulting in acute pain and a subsequent diagnosis of a distal femur fracture. Despite the incident occurring, there was no documentation in the clinical record on the day of the event, including progress notes, incident reports, or assessments. Notification to the physician and the resident's family was also not documented on the day of the incident. Documentation of the change in condition and related assessments were completed days later, and staff interviews confirmed that required documentation and reporting protocols were not followed at the time of the incident. Additionally, the facility did not provide requested documentation for another resident in a timely manner during the survey process. When therapy documentation was requested, there was a significant delay in providing the records, exceeding the expected two-hour turnaround time. The delay persisted despite multiple reminders to facility leadership, and the required documents were only provided the following day. There were also delays and missing documentation related to staff qualifications and training for a contracted CNA, with competency checklists and orientation records not readily available and only submitted after further requests. Facility policy requires prompt and thorough documentation of incidents, changes in condition, and communication with physicians and families. The failure to document the incident, assessments, and notifications as required, as well as the delay in providing requested records, resulted in incomplete and inaccurate medical records and hindered the survey process. These deficiencies were confirmed through record reviews, staff interviews, and policy review.
Failure to Maintain Sanitary Conditions in Dishwashing
Penalty
Summary
The facility failed to ensure that dishes and utensils were cleaned under sanitary conditions, which could result in residents becoming ill. During an initial walk-through of the kitchen, it was observed that the temperature gauge on the dishwasher had not been working since December 31, 2023. The senior cook, who was responsible for the kitchen, stated that he had been using an external thermometer to manually check the dishwasher temperature. However, the temperature readings during the wash cycle varied significantly, with readings of 118 degrees, 140 degrees, and 203 degrees, none of which consistently met the required temperature for sanitization. Additionally, the senior cook admitted to not properly documenting the temperature readings on the dishwasher temperature log from January 1, 2024, to January 22, 2024, and falsely indicated that he had checked the temperature for all three meals each day, even on days he was not present at work, as confirmed by his time card records. The facility's policy and the dishwasher instruction manual both require specific temperature ranges for the wash and rinse cycles to ensure proper sanitization, which were not consistently met or documented. An interview with the Administrator revealed that the facility was aware of the issue and was expecting a new dishwasher to be installed. The Administrator also confirmed that the expectation was for the dishwasher temperature log to be initialed by the staff who checked the temperature each meal. The failure to maintain and document proper dishwasher temperatures as per the facility's policy and the dishwasher's instruction manual could lead to unsanitary conditions and potential illness among residents. The facility's policy requires the wash cycle to be between 150 to 165 degrees Fahrenheit and the rinse cycle to be between 150 to 180 degrees Fahrenheit, which were not consistently achieved or recorded during the observed period.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to three residents, as required by policy and regulations. Resident #3, who was cognitively intact with a BIMS score of 13, was transferred to the hospital due to a fall resulting in a pelvic fracture. Although the resident's emergency contact was notified via telephone, there was no documentation of a written notice provided to the resident regarding the transfer. The facility's Administrator confirmed that the facility does not provide written statements for hospital transfers, which is against the facility's policy and regulatory requirements. Similarly, Resident #37, who had severe cognitive impairment with a BIMS score of 7, was transferred to the hospital due to shortness of breath. The clinical record lacked evidence of a written notice of transfer/discharge being provided to the resident or their representative. Interviews with the Director of Nursing and the Administrator revealed that the facility's practice was to notify the resident's representative verbally in case of an emergency transfer, but no written notice was provided, which contradicts the facility's policy. This failure to provide written notification could result in residents having an unsafe discharge.
Failure to Properly Assess and Administer Pain Medications
Penalty
Summary
The facility failed to assess and administer pain medications according to accepted standards of clinical practice for two residents. Resident #16, who has severe cognitive impairment, was prescribed Acetaminophen 325 mg to be given 650 mg by mouth every 4 hours as needed for pain, not to exceed 3,000 mg per day. The Medication Administration Record (MAR) showed that the medication was administered on two occasions in January 2024 with a pain scale of 5. However, the orders did not include a pain scale, which is necessary to determine the appropriateness of the medication for the level of pain experienced by the resident. Resident #30, who is cognitively intact, had multiple pain medication orders, including Acetaminophen, Ibuprofen, and Oxycodone-Acetaminophen. The MAR for December 2023 and January 2024 revealed inconsistencies in the administration of these medications, with some medications not being administered at all and others being administered without a specified pain scale. Interviews with the Clinical Care Coordinator and the Director of Nursing highlighted a discrepancy in the facility's understanding and implementation of pain scale requirements for PRN pain medications. The facility's policy on the administration of PRN medications states that they should be administered consistent with the prescriber's parameters and registered nurse's procedures, but this was not followed in these cases.
Failure to Implement Pharmacy Medication Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacy medication recommendation was reviewed and implemented for a resident diagnosed with Major Depressive Disorder and epilepsy. The resident was on anticonvulsant medication therapy with Divalproex Sodium, and a pharmacy consultation report recommended monitoring valproic acid trough concentration. However, the clinical record did not show that the valproic acid levels were drawn as recommended. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that there was no clear responsibility for following up on pharmacy recommendations, and the resident's Depakote level was missed during leadership transitions. The DON acknowledged that pharmacy reviews should be completed timely and expected that pharmacy reviews be presented to the Medical Director or the resident's Primary Care Provider the next business day. The facility's policy on physician/practitioner orders emphasized the importance of processing and transcribing orders immediately upon receipt. Despite this policy, the facility failed to ensure that the pharmacy's recommendation for monitoring valproic acid levels was followed, resulting in a deficiency in the resident's care.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to ensure that a resident's clinical record included the required information for transfer/discharge. Resident #37, who had severe cognitive impairment and multiple diagnoses including COPD, endocarditis, and supraventricular tachycardia, was discharged to Yavapai Regional Medical Center due to shortness of breath. However, a review of the clinical record revealed no evidence of a discharge summary. The Director of Nursing acknowledged the absence of the discharge summary and stated it should have been completed in a timely manner. The facility Administrator was unsure of the resident discharge policy and needed to check it to determine when a discharge summary should be provided.
Failure to Revise Care Plans Following Falls
Penalty
Summary
The facility failed to ensure that care plans were revised for two residents following falls. Resident #15, who was admitted with hemiplegia and epilepsy, experienced a fall on 7/4/23. Despite this incident, no new interventions were documented in the clinical record until 8/21/23. Similarly, Resident #21, admitted with vascular dementia and generalized anxiety disorder, fell on 9/27/22 and sustained a head injury resulting in a subdural hematoma. However, no care plan for falls was documented until 11/20/22, and no immediate interventions were put in place following the fall on 9/27/22. Interviews with staff revealed that the expected protocol for falls, including immediate assessment, notification of relevant parties, and updating the care plan with new interventions, was not followed. The Registered Nurse and Licensed Practical Nurse both confirmed that interventions were either delayed or missing entirely. The Administrator also acknowledged that interventions should have been implemented sooner and that the care plans were not updated promptly to reflect the residents' needs following their falls.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 8 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Prescott
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Granite Creek Health & Rehabilitation Center | 0 mi | ★★★★★ | 5 | 0 |
| Haven Health Prescott, Llc | 1.2 mi | ★★★★★ | 0 | 0 |
| Mountain View Manor | 3 mi | ★★★★★ | 0 | 0 |
| Prescott Valley Nursing & Rehabilitation | 8.3 mi | ★★★★★ | 3 | 0 |
| Haven Of Cottonwood | 27.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.