Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Staff failed to follow infection control practices during resident care, including not using EBP with gowns and signage for residents with wounds or indwelling devices, not performing hand hygiene or changing gloves between dirty and clean tasks, and touching clean items and surfaces with contaminated gloves. The facility also had incomplete TB screening records for several residents, including missing documentation that TSTs were read and missing annual TB evaluations.
The facility failed to maintain an IPCP that included antibiotic stewardship and infection surveillance protocols. The DON, who served as the Infection Preventionist, could not locate surveillance documentation for several months, including the monthly infection control log and infection map required by policy. The facility matrix showed three residents receiving antibiotics, but there was no documentation that those prescriptions were reviewed through the antibiotic stewardship process.
Missing Informed Consent for Psychotropic Medications: The facility failed to obtain and document informed consent before giving psychotropic medications to four residents. Records for residents with dementia, depression, anxiety, psychotic disturbance, and sexually aggressive behaviors showed orders for antipsychotic, antidepressant, antianxiety, and related medications without documentation that the resident or representative received education on risks, benefits, and alternatives. The DON said the consents were incomplete, and the Administrator acknowledged the facility did not have psychotropic medication consents for residents receiving those medications.
Advance directive and code status documentation was missing for three residents. Their charts had no advance directive forms, no code status entries on the Physician Order Sheet, and care plans did not address code status. Two residents told staff their preferences, including one who wanted DNR status and one who wanted full code status, but the information was not readily available in the EMR. Staff interviews showed one RN treated residents as full code if no scanned proof was found, while the DON and SSD said code status should be saved in the EMR and available in the chart.
Unsafe and Poorly Maintained Resident Areas: Observation and interview showed shower rooms with mold/mildew-like buildup, missing and non-intact tiles, peeled paint, and damaged seating; a common-area chair with torn vinyl; and resident rooms with gaps around HVAC units, a clogged sink drain, peeled paint, and a ceiling tile out of place. A resident reported empty soap in the shower, mold on the wall, a sink that would not drain, and prior bugs entering through an unsealed HVAC gap.
Missing transfer, discharge, and bed-hold documentation: The facility failed to provide required written transfer/discharge notices for several residents transferred to the hospital, including the reason for transfer and Ombudsman and Protection & Advocacy contact information, and some bed-hold forms did not include the daily bed-hold rate. A resident discharged home also lacked a discharge summary with a recapitulation of the stay. Interviews confirmed staff were responsible for these notices and that residents should receive the transfer/discharge and bed-hold forms, appeals info, and Ombudsman contact information.
A resident’s annual comprehensive MDS was not completed within the required timeframe. The resident had prior annual and quarterly MDS assessments, but the next annual assessment remained in progress past the due date. The DON said she had taken over MDS completion because there was no MDS Coordinator, and the newly hired MDS Coordinator was still in training. The DON acknowledged the assessment was not completed on time, and the Administrator said MDS assessments were expected to be completed within required timeframes.
Failure to complete significant change MDS assessments after hospice election for two residents. The record showed that both residents were admitted to hospice, but no significant change MDS was completed within the required 14-day timeframe. The DON said she was responsible for MDS completion because there was no MDS Coordinator, and the Administrator stated he expected the assessments to be completed on time.
Quarterly MDS assessments were not completed on time for six residents. Record review showed each resident had a prior OBRA assessment, but the next quarterly MDS was still incomplete and unsubmitted after the ARD and completion due date had passed. The DON said she had taken over MDS completion because there was no MDS Coordinator, and a new MDS Coordinator was still in training; the Administrator said he expected assessments to be completed within required time frames.
Incomplete and Non-Individualized Care Plans: The facility failed to develop and implement comprehensive, person-centered care plans for two residents. One resident’s plan did not reflect multiple active diagnoses, including dementia with psychotic disturbance, heart failure, a-fib, GERD, peptic ulcer, and stress incontinence, or ordered meds such as Donepezil, Duloxetine, Esomeprazole, Furosemide, Namenda, Rexulti, and Xarelto. Another resident’s plan did not address CHF, COPD, pain meds, wound care, mobility limitations, or the use of a Hoyer lift for transfers. The DON and Administrator stated care plans should be individualized, timely, and revised when orders or conditions change.
Improper transfer techniques and failure to follow resident transfer needs were observed for two residents. One resident with dementia, anxiety, and chronic pain was lifted from bed to wheelchair without a gait belt, using the resident’s underarms and pants while the resident could not bear weight. Another resident with CHF, a toe amputation, and glaucoma was transferred from wheelchair to bed without the ordered Hoyer lift or a gait belt, despite staff stating the resident had required a Hoyer lift for the prior two days; the CNA lifted the resident under the arms while the resident was unable to bear weight.
Dialysis communication forms were not completed for a resident receiving ESRD dialysis, and the record lacked documentation of communication between facility staff and the dialysis provider about treatment completion, weights, BP, fluid removal, vascular access assessment, medication or treatment changes, orders, or complications. The resident’s care plan identified ongoing dialysis treatment and monitoring needs, while the DON acknowledged the forms were not consistently completed and the Administrator stated staff were expected to ensure they were completed.
An unlocked treatment cart containing prescription creams, powders, and antibiotic capsules was left unattended beside the nurse's station on multiple occasions while residents in wheelchairs were nearby and staff walked past it. The DON, an LPN, and the Administrator stated that treatment or medication carts should be locked when unattended or out of view, and the facility policy required drugs and biologicals to be stored in locked compartments.
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.
Infection Control Failures in EBP, Hand Hygiene, and TB Screening
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for three residents who required them because of wounds or indwelling devices. For one resident with a suprapubic catheter, the nurse entered the room with supplies, performed hand hygiene, put on gloves, and provided catheter care without wearing a gown. For another resident receiving colostomy care, the Director of Nursing entered the room without EBP signage posted outside, wore gloves but no gown, and completed the procedure. For a third resident receiving incontinent care, two CNAs entered without hand hygiene, wore gloves but no gowns, and provided care while the resident remained in bed and was later transferred with a Hoyer lift. Staff interviews confirmed they expected EBP to include gowns and gloves for residents with wounds or indwelling devices, and one CNA stated residents requiring EBP should have signage posted outside the room. The facility also failed to perform hand hygiene and change gloves between contaminated and clean care activities during resident care for multiple residents. During incontinent care for one resident, CNAs entered without hand hygiene, moved the resident to the bathroom, handled a urine-soiled brief, touched the sink faucet and clean supplies while wearing the same contaminated gloves, and continued perineal care without changing gloves or performing hand hygiene. During care for another resident, a CNA entered without hand hygiene, removed a wet brief, cleansed the resident, touched the blanket, bed controls, and bedside table while still wearing the same gloves, and only performed hand hygiene after transporting trash. Similar failures were observed during care for other residents, including not performing hand hygiene before care, not changing gloves after contact with soiled briefs, using the same wipe repeatedly, touching clean items and environmental surfaces with contaminated gloves, and delaying hand hygiene until after leaving the room or handling soiled items. The facility also failed to complete and maintain required TB screening documentation for five residents. Records showed missing documentation that initial TSTs were read, missing documentation of second-step testing in some cases, and missing annual TB screening or evaluation documentation for multiple residents. One resident had no documentation of TB screening completed before or upon admission, and several residents lacked documentation of annual TB evaluation for the following year. The DON stated the facility expected TB screening and documentation to be completed in accordance with policy and acknowledged the identified records were incomplete.
Missing antibiotic stewardship and infection surveillance documentation
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program that included an antibiotic stewardship program with infection surveillance and antibiotic use protocols. The facility policy stated that the antibiotic stewardship program was to promote appropriate antibiotic use, monitor adherence to evidence-based criteria, and compile reports related to antibiotic usage and resistance data. The infection surveillance policy also required a monthly infection control log and an updated map of infections to identify clusters or trends. Review of the Infection Tracking Folders for June 2025 through June 2026 showed no infection control log for June 2025 through October 2025, no map of infections for June 2025 through October 2025, and no Infection Tracking Folders provided for November 2025 through June 2026. The facility matrix dated 06/15/26 showed three residents currently receiving antibiotics, but there was no surveillance documentation showing those prescriptions had been reviewed through the antibiotic stewardship process. The DON, who was also the Infection Preventionist, said she could not locate the antibiotic stewardship surveillance for November 2025 through June 2026 and stated that she reviewed the antibiotic stewardship and surveillance information with the physician monthly and with department heads weekly. The Administrator stated that antibiotic stewardship and surveillance were the DON's responsibility and that he expected all required information to be completed.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before administering psychotropic medications to four sampled residents. Review of the facility policy titled, Psychotropic Medication Use, showed that residents and/or their representatives have the right to decline psychotropic treatment and that staff and the physician will review the risks of not taking the medication as well as appropriate alternatives. However, for Residents #3, #6, #21, and #27, the records showed psychotropic medication orders without documentation that the resident or representative received education about the risks, benefits, and alternatives or provided informed consent before treatment. Resident #3 had diagnoses including unspecified dementia with psychotic disturbance, depression, and myasthenia gravis, and had orders for Rexulti and duloxetine. Resident #6 had diagnoses of unspecified dementia and sexually aggressive behaviors, and had orders for venlafaxine and Depo-Provera for sexually aggressive behaviors. Resident #21 had diagnoses of major depressive disorder and generalized anxiety disorder, with orders for buspirone, Remeron, and Abilify. Resident #27 had diagnoses of unspecified dementia with mood disturbance and anxiety disorder, with orders for sertraline and olanzapine. During interviews, the DON stated the psychotropic medication consents were incomplete and on her list to complete, and the Administrator acknowledged the facility did not have psychotropic medication consents for residents receiving those medications.
Advance Directive and Code Status Documentation Missing
Penalty
Summary
The facility failed to ensure that advance directive decisions, including code status, were documented and readily available in the medical record for three residents. For Resident #27, the chart contained no advance directive form, no documentation of code status, no Physician Order Sheet entry reflecting expressed code status, and the care plan did not address code status. Resident #28 had the same missing documentation in the medical record, including no advance directive form, no code status documentation, no Physician Order Sheet entry, and no care plan addressing code status. Resident #36 also had no advance directive form in the chart, no documentation of code status, no Physician Order Sheet entry reflecting expressed code status, and a care plan that did not address code status. During interview, Resident #28 stated a preference for DNR status and said he/she had spoken with the SSD about advance directives the day before. Resident #36 stated a preference for full code status and said he/she had spoken with the SSD about code status that week. Staff interviews showed RN A looked for code status in the medical record and considered a resident full code if no scanned proof was found, while the Administrator, DON, and SSD stated code status should be in the chart and saved in the EMR, with audits expected within 72 hours of admission or a code status change.
Unsafe and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment as required by its policy. Observation of the men's shower room showed a black substance buildup in a shower stall corner below the grab rail, a white substance buildup on most of the shower floor, and a bench seat with a non-intact Formica edge. Observation of the women's shower room showed missing ceramic tiles on the shower wall, a missing outside corner tile and non-intact ceramic baseboard section near the floor, a black substance buildup below the toilet near the floor, and peeled paint near two HVAC vents on the ceiling. The Housekeeping Supervisor stated the showers should be cleaned and disinfected every day, that mold and mildew should be absent, and that missing ceramic tiles had not been reported. Additional observations showed a blue chair at the nurse's station/common area with non-intact vinyl on the backrest and seat edge, resident room HVAC units with approximately 1-inch gaps between the units and the wall allowing visible daylight into the room, a non-intact vinyl cove baseboard, a clogged lavatory drain, peeled paint near the lavatory, and an L-shaped ceiling tile lying above the ceiling frame. A resident stated the soap was usually empty in the shower, there was mold on the wall, the sink did not drain, and an unsealed gap around the HVAC units had allowed bugs into the room in the past. Maintenance and the Administrator stated there should not be air gaps between HVAC units and the wall and that paint in resident areas should be intact.
Missing transfer, discharge, and bed-hold documentation
Penalty
Summary
The facility failed to provide required written transfer and discharge information for five residents who were transferred to the hospital, including complete bed-hold notices, the daily bed-hold rate, and required contact information for the Office of the State Long-Term Care Ombudsman and the Protection and Advocacy agency. For Residents #4, #5, #11, #18, and #33, the record review showed no documentation that the resident or resident representative received transfer/discharge notices with the reason for transfer, and no documentation that the facility notified the Ombudsman after the transfers or discharges. The facility also did not have a policy available for addressing transfer/discharge notices, bed-hold notices, or notification of the Ombudsman or advocacy agency contact information. Resident #5 and Resident #11 had Bed-Hold and Return Notification forms that did not include the daily bed-hold rate, and Resident #33's forms also lacked the daily bed-hold rate. Resident #35 was discharged home, and the record did not contain documentation that the resident and/or resident representative received a discharge summary with a recapitulation of the resident's stay. The facility policy titled, Discharge Summary and Plan, stated that a discharge summary should include a recapitulation of the resident's stay and a final summary of the resident's status at discharge. During interviews, the Administrator stated staff were responsible for completing transfer/discharge notices, bed-hold notices, and required notifications, and the DON and Social Services Designee stated residents should receive the transfer/discharge and bed-hold forms, along with the daily bed-hold rate, appeals process, and Ombudsman contact information.
Failure to Complete Annual MDS Assessment on Time
Penalty
Summary
The facility failed to complete a comprehensive MDS assessment within the required time frame for one resident. Resident #10 was admitted to the facility and had an annual MDS assessment completed on 04/10/25, followed by quarterly MDS assessments completed on 07/11/25, 10/11/25, and 01/02/26. The next annual comprehensive MDS had an ARD of 04/10/26 and remained in progress, and the assessment was due no later than 04/11/26. Record review showed the annual comprehensive MDS assessment was not completed within 366 days of the previous comprehensive assessment as required by the RAI Manual. During interview, the DON said she had assumed responsibility for completing MDS assessments because the facility did not have an MDS Coordinator, and the newly hired MDS Coordinator had been employed for two weeks and was still in training. The DON acknowledged the annual MDS assessment for Resident #10 was not completed within the required time frame, and the Administrator stated he expected MDS assessments to be completed within the required time frames.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to timely complete significant change MDS assessments within 14 days of admission to hospice services for two residents. Review of the record showed that one resident was admitted to hospice on 08/28/25 and had no completed significant change MDS dated on or after that date, and another resident was admitted to hospice on 05/20/26 and also had no completed significant change MDS dated on or after that date. The report states that no significant change MDS was completed within 14 days following hospice election for either resident. The facility policy titled, MDS Completion and Submission Timeframes, stated that resident assessments would be conducted and submitted in accordance with current federal and state submission timeframes. During interview, the DON stated she was responsible for completing MDS assessments because there was no MDS Coordinator, and that a new MDS Coordinator had been hired two weeks earlier and was still in training. She said she expected MDS assessments, including significant change assessments, to be completed and submitted on time, and that if a resident was admitted or discharged from hospice care, a significant change MDS would be expected within 14 days. The Administrator also stated he would expect a significant change MDS to be completed on time and in the appropriate timeframe.
Quarterly MDS Assessments Not Completed on Time
Penalty
Summary
Quarterly MDS assessments were not completed within the required time frames for six sampled residents: Residents #2, #7, #9, #16, #22, and #29. Review of the records showed each resident had a prior OBRA assessment completed, followed by a quarterly assessment with an ARD and completion due date that had passed, but the quarterly MDS remained incomplete and unsubmitted. The residents’ prior assessments included quarterly, annual, or admission MDSs completed earlier in 2026, and the next quarterly assessments were still pending at the time of review. During interview, the DON stated she had assumed responsibility for completing MDS assessments because the facility did not have an MDS Coordinator, and that a new MDS Coordinator had been employed for two weeks and was still in training. The DON acknowledged the quarterly MDS assessments for the six residents were not completed within the required time frames. The Administrator stated he expected MDS assessments to be completed within the required time frames.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that reflected residents’ current diagnoses, physician orders, and care needs for two of 16 sampled residents. The facility also did not provide a care plan policy. Surveyors reviewed the records of two residents and found that their care plans did not include multiple active diagnoses, ordered medications, treatments, or interventions that were specific to each resident’s needs. For one resident, the medical record showed diagnoses including myasthenia gravis, heart failure, depression, atrial fibrillation, history of venous thrombosis and embolism, polyneuropathy, GERD, peptic ulcer, stress incontinence, and unspecified dementia with moderate psychotic disturbance. The resident had physician orders for Donepezil, Duloxetine, Esomeprazole, Furosemide, Namenda, Rexulti, and Xarelto. The care plan, last revised on 06/11/26, did not address dementia with psychotic disturbances, myasthenia gravis, heart failure, atrial fibrillation, GERD, peptic ulcer, or stress incontinence, and did not address the medications with person-centered interventions. For the other resident, the medical record showed diagnoses of chronic diastolic heart failure, COPD, malignant neoplasm of the prostate, acquired absence of the right toe, and unspecified glaucoma. The resident had orders for Morphine as needed for pain, Hydrocodone-Acetaminophen for pain, use of a Hoyer lift for all transfers, heel protector use to the left foot, and wound care orders for the left foot and right forearm. The care plan, revised 05/21/26, did not address Morphine or Hydrocodone-Acetaminophen with person-centered interventions, did not address the left foot and right forearm wounds, did not address mobility limitations, and did not address the use of a mechanical lift for transfers. During interviews, the DON and Administrator stated that care plans should be individualized, timely, and revised when orders or conditions change.
Improper Transfer Techniques and Failure to Follow Resident Transfer Needs
Penalty
Summary
The facility failed to ensure staff followed residents’ assessed transfer needs and used appropriate transfer techniques and equipment for two residents during transfers. During an observation, two CNAs transferred one resident from bed to wheelchair by sitting the resident on the side of the bed, not placing a gait belt, placing their arms under the resident’s underarms, and lifting the resident by pulling on the resident’s pants and underarms while the resident was unable to bear weight. The resident had diagnoses of dementia with mood disturbance, anxiety disorder, and chronic pain syndrome, and the lift/transfer evaluation stated the resident was to bear full weight, be cooperative with transfers, assist with transfer from bed to chair, and fully assist with repositioning. The care plan did not address how the resident transferred. During another observation, a CNA transferred a second resident from wheelchair to bed after being told by another staff member that the resident required a Hoyer lift for transfers. The CNA said he/she was not aware of the downgrade and proceeded without a gait belt or mechanical lift, placing hands under the resident’s underarms while the resident looped his/her hands around the CNA’s neck and was lifted from the wheelchair despite being unable to bear weight. The resident had diagnoses of chronic diastolic heart failure, acquired absence of a right toe, and glaucoma, and had an order for a Hoyer lift for all transfers. The lift/transfer evaluation showed the resident could bear partial weight and assist with transfers, but the care plan did not address how the resident transferred. The DON stated staff should always use a gait belt if doing a transfer without a mechanical lift, and CNAs should use the care plan and Kardex or ask a nurse or therapy if needed.
Dialysis communication forms not completed
Penalty
Summary
The facility failed to ensure dialysis communication forms were completed to support ongoing coordination and collaboration of care between facility staff and the dialysis provider for one resident receiving dialysis. Resident #5 had diagnoses of ESRD and dependence on renal dialysis, with an order for dialysis appointments every Monday, Wednesday, and Friday. Review of the resident’s dialysis communication forms showed they were not completed for 30 of 30 opportunities, and the medical record did not contain documentation of communication between the dialysis provider and facility staff regarding treatment completion, pre- and post-dialysis weights, blood pressure readings, fluid removal, vascular access assessment, medication or treatment changes, dialysis orders, or complications requiring follow-up care. The resident’s care plan identified the need for ongoing dialysis treatment and monitoring. During interview, the resident stated he/she sometimes received a communication form when going to dialysis but did not know what happened to it once it reached the dialysis center. The DON stated the nurse sending the resident to dialysis was responsible for completing the dialysis communication form and the receiving nurse was responsible for documenting the information received upon the resident’s return, and acknowledged the forms were not consistently completed. The Administrator stated staff were expected to ensure dialysis communication forms were completed.
Unattended treatment cart left unlocked near residents
Penalty
Summary
The facility failed to keep one treatment cart locked when it was left unattended out of two treatment and medication carts. The cart contained prescription creams, powders, and antibiotic capsules. During observation, the unlocked treatment cart was left beside the nurse's station with no staff in the area while residents in wheelchairs were nearby on multiple occasions. Staff members, including the DON, CMT F, LPN H, and a CNA, were observed walking past or near the unattended cart while it remained unlocked. On one observation, the cart remained unlocked and unattended for several minutes until the MDS Coordinator locked it. On another observation, the cart was again left unlocked beside the nurse's station while staff moved around the area and a CNA passed by with a bed. Later, LPN H opened the cart, walked away leaving it unattended, and returned several minutes later to lock it. The facility's policy stated that drugs and biologicals are to be stored in locked compartments and that compartments containing drugs and biologicals are locked when not in use. The DON, LPN H, and the Administrator all stated that treatment or medication carts should be locked when left unattended or out of view.
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 | ★★★★★ | 20 | 0 |
| Southbrook Nursing Center | 16.5 mi | ★★★★★ | 4 | 0 |
| Madison Medical Center | 16.6 mi | ★★★★★ | 5 | 0 |
| Farmington Presbyterian Manor | 16.7 mi | ★★★★★ | 5 | 0 |
| Community Manor | 17.2 mi | ★★★★★ | 2 | 0 |
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