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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Baptist Homes Of Arcadia Valley during CMS and state inspections, most recent first.
The facility did not have a Quality Assurance and Performance Improvement Plan (QAPI) in place, lacking necessary policies and protocols for quality management. The DON, who began in January 2025, found no existing documentation of a QAPI Plan and was attempting to organize one without having implemented it yet.
The facility failed to implement a QAPI Plan or PIPs, as confirmed by the DON, potentially affecting all 25 residents. The absence of these plans was identified through interviews and record reviews.
The facility did not maintain quarterly QAPI committee meetings with the required members, nor did it have a QAPI policy or documentation. The DON confirmed the absence of a QA committee and relevant documentation.
The facility failed to maintain an effective antibiotic stewardship program as part of its Infection Prevention and Control Program. Despite having a policy in place, the facility did not provide documentation for the program and relied on a pharmacy consultant for monthly antibiotic reports. The DON admitted the program was not fully operational, affecting the facility's ability to monitor antibiotic use for its 25 residents.
The facility failed to maintain proper infection control practices during wound and catheter care for residents, with staff not performing appropriate hand hygiene and glove-changing techniques. Additionally, the facility did not correctly screen residents for tuberculosis as required by state regulations, with incomplete or missing documentation of TB screening. Staff interviews confirmed that enhanced barrier precautions were not consistently implemented, and the facility lacked a comprehensive infection control policy.
A facility failed to document communication between the facility and the dialysis center for a resident with ESRD. The resident had orders for dialysis thrice weekly and site assessments every shift, but no Dialysis Communication Reports were maintained. Interviews revealed the facility was not using a dialysis communication sheet, contrary to policy requirements for coordinated care.
The facility failed to maintain a medication error rate below five percent, resulting in a 13.33% error rate. Errors involved the improper administration of insulin due to staff not priming insulin pens as required. This affected four residents, with staff interviews revealing a lack of understanding of proper procedures.
Failure to Develop a QAPI Plan
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI), which is essential for guiding the facility's efforts in maintaining and improving care and services. The facility, with a census of 25, did not have a QAPI plan that included necessary policies and protocols for identifying and correcting quality deficiencies, tracking and measuring performance, and establishing goals and thresholds for performance measurement. During an interview, the Director of Nursing (DON), who started in January 2025, stated that she found no documentation of a previous QAPI Plan and was in the process of organizing it but had not yet implemented anything.
Lack of QAPI Plan and PIPs in Facility
Penalty
Summary
The facility failed to ensure that the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This deficiency was identified through interviews and record reviews, revealing that the facility did not have a QAPI Plan or Performance Improvement Plans (PIPs) in place. The Director of Nursing (DON) confirmed during an interview that there was no documentation of a QAPI Plan or PIPs, and the facility was in the process of establishing these plans. This lack of documentation and planning had the potential to affect all 25 residents in the facility.
Failure to Maintain QAPI Meetings and Documentation
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility, which had a census of 25, did not provide any policy or documentation related to QAPI. A review showed no evidence that the facility held the minimum required quarterly Quality Assessment and Assurance (QAA) meetings with the necessary members. During an interview, the Director of Nursing (DON) confirmed that the facility did not have a QAPI policy and procedure in place, nor was there a QA committee at the time. Additionally, there was no documentation available for review.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program (ICIP) that included an antibiotic stewardship program, as required by their policy. The policy, revised in December 2016, outlined that antibiotics should be prescribed and administered under the guidance of the facility's antibiotic stewardship program. It also required the collection and documentation of antibiotic usage and outcome data using a facility-approved antibiotic surveillance tracking form. This data was intended to guide decisions for improving individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. However, the facility did not provide documentation for the Antibiotic Stewardship Program, indicating a lack of adherence to their own policy. During the review period from February 1 to March 31, eight residents received antibiotics, and as of March 4, two residents were currently receiving antibiotics. Despite this, the facility did not conduct its own infection surveillance, relying instead on a monthly antibiotic report completed by the facility's pharmacy consultant company. The Director of Nursing (DON) acknowledged that the Infection Control program was not fully operational, which contributed to the deficiency in maintaining an effective antibiotic stewardship program. This deficiency had the potential to affect all 25 residents in the facility.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility staff failed to maintain appropriate infection control practices during wound care and catheter care for two residents. Observations revealed that staff did not perform proper hand hygiene and glove-changing techniques. For instance, during catheter care for a resident, a CNA did not use a clean wipe for each cleaning motion and failed to perform hand hygiene after removing gloves. Similarly, during wound care for another resident, an RN did not wear a gown, did not change gloves between tasks, and failed to perform hand hygiene after removing gloves. Additionally, the facility did not correctly screen residents for tuberculosis (TB) as required by state regulations. The medical records of five residents showed incomplete or missing documentation of TB screening. For example, one resident's record lacked an annual tuberculin skin test (TST) or screening for 2024, while another resident's record showed a TST with no read date. The facility's policy requires TB screening on admission, during outbreaks, and annually, but these procedures were not followed. Interviews with staff, including an RN and the Director of Nursing, confirmed that enhanced barrier precautions (EBP) were not consistently implemented. Staff acknowledged that gowns and gloves should be worn during care for residents with indwelling catheters, wounds, or MDRO infection risks. However, observations showed that EBP signage was missing, and staff did not consistently use gowns and gloves as required. The facility also lacked a comprehensive infection control policy, contributing to these deficiencies.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to provide documentation of communication between the facility and the dialysis center for a resident with end-stage renal disease (ESRD) who required dialysis services. The resident had a physician's order for dialysis three times a week and specific orders to assess the dialysis site for bleeding, infection, and other indicators every shift. Despite these orders, the facility did not maintain Dialysis Communication Reports, which are essential for ensuring coordinated care between the facility and the dialysis center. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed that the facility was not using a dialysis communication sheet, which should have been sent to the dialysis unit with the resident's information. The DON acknowledged that the dialysis facility should fill out the dialysis portion and return it with the resident, but this process was not being followed. This lack of communication documentation represents a failure to adhere to the facility's policy on dialysis care, which emphasizes the importance of coordinated care planning and communication for residents receiving dialysis.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 13.33% error rate during medication administration. This deficiency affected four residents out of 16 sampled, with a total of 30 opportunities and four errors. The errors were primarily due to the failure to prime insulin pens before administration, as required by the manufacturer's instructions. Specifically, insulin pens for Fiasp and Humalog were not primed before use, which is necessary to ensure the correct dosage is administered. The report highlights specific instances where staff, including a Registered Nurse and a Certified Medication Technician, did not follow the proper priming procedures for insulin pens. Interviews with staff revealed a lack of understanding or adherence to the priming requirements, with some staff incorrectly believing that priming was only necessary when the pen was new. The facility also lacked a specific policy regarding insulin administration, contributing to the inconsistency in practice. The Director of Nursing and the Administrator acknowledged the expectation for staff to follow proper procedures, but the deficiency indicates a gap in training or policy enforcement.
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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.
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Nursing homes near Ironton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belleview Valley Nursing Home | 12.4 mi | — | 14 | 1 |
| Southbrook Nursing Center | 16.5 mi | ★★★★★ | 4 | 0 |
| Madison Medical Center | 16.6 mi | ★★★★★ | 5 | 0 |
| Farmington Presbyterian Manor | 16.7 mi | ★★★★★ | 0 | 0 |
| Community Manor | 17.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.