Baptist Homes of Arcadia Valley

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to implement Enhanced Barrier Precautions (EBP - precautions used during high-contact resident care activities for residents infected or colonized with a multidrug-resistant organism (MDRO - microorganisms resistant to one or more classes of antimicrobial agents) or for residents with a chronic wound and/or an indwelling medical device) for three residents (Residents #5, #18, and #30); failed to perform hand hygiene and change gloves between contaminated and clean care activities during resident care for six residents (Residents #5, #8, #9, #18, #27, and #30); and failed to complete and/or maintain required tuberculosis (TB - an infectious bacterial disease that primarily affects the lungs) screening and related documentation for five residents (Residents #5, #8, #11, #18, and #27). [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to with infection surveillance and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. The facility census was 29. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was obtained and documented before administering psychotropic (a medication that affects brain activities associated with mental processes and behavior) medications for four residents (Residents #3, #6, #21, and #27) out of four sampled residents. This failure prevented the residents and/or their representatives from receiving information regarding the risks, benefits, and alternatives associated with psychotropic medication use before treatment. The facility census was 29. Review of the facility's policy titled, Psychotropic Medication Use, dated July 2022, showed:- Residents will not receive medications that are not clinically indicated to treat a specific condition;- Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' advance directive decisions, including code status, were documented and readily available in the medical record for three residents (Residents #27, #28, and #36) out of 12 sample residents. The facility census was 29. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. The facility census was 29. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed:- Residents are provided with a safe, clean, comfortable and home-like environment and encouraged to use their personal belongings to the extent possible;- Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences;- The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including a clean, sanitary and orderly environment. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide required written transfer and discharge information, including complete bed-hold notices and required advocacy agency contact information for hospital transfers and notify the Office of the State Long-Term Care Ombudsman of resident transfers or discharges for five residents (Residents #4, #5, #11, #18, and #33). The facility also failed to provide a discharge summary that included a recapitulation of the resident's stay for one resident (Resident #35) out of one sampled resident discharged to the community. The facility census was 29. The facility did not provide a policy for addressing transfer/discharge notices, bed-hold notices, notification of the Office of the State Long-Term Care Ombudman or required advocacy agency contact information. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) within the required time frame for one resident (Resident #10) out of nine sampled residents. This failure had the potential to affect the resident's comprehensive assessment and care planning. The facility's census was 29. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2019, showed:- Assessments be completed and submitted according to federal and state requirements. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed:- The next comprehensive assessment be completed within 366 days of the previous comprehensive assessment. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessment within 14 days of admission to hospice services for two residents (Residents #1 and #30) out of two sampled residents. The facility census was 39. Review of the facility's policy titled, MDS Completion and Submission Timeframes, revised July 2017, showed:- Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Review of the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual, dated October 2025, showed:- A significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) assessments within the required time frames for six residents (Residents #2, #7, #9, #16, #22, and #29) out of 12 sampled residents. This failure had the potential to affect the residents' comprehensive assessments and care planning. The facility's census was 29. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2019, showed:- Assessments be completed and submitted according to federal and state requirements. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans that reflected residents' current diagnoses, physician orders, and care needs through measurable, resident-specific interventions for two residents (Residents #3 and #30) out of 16 sampled residents. The facility census was 29. The facility did not provide a care plan policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented residents' assessed transfer needs and utilized appropriate transfer techniques and equipment during transfers for two residents (Residents #27 and #30) out of four sampled residents. The facility census was 29. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis (process for removal of waste and excess water from the blood due to kidney failure) communication forms were completed to support ongoing coordination and collaboration of care between facility staff and the dialysis provider for one resident (Resident #5) out of one sampled resident receiving dialysis. The facility's census was 29. Review of the facility's policy titled, Dialysis Care, undated, showed:- Purpose is to adequately assess resident needs and provide care goals which achieve the highest practicable level of care to residents with end-stage renal disease (ESRD - chronic irreversible kidney failure) receiving dialysis;- Did not address ongoing coordination and collaboration between the facility and dialysis. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one treatment cart locked when left unattended out of two treatment and medication carts. The treatment cart contained prescription creams, powders, and antibiotic capsules. This had the potential to affect all residents. The facility's census was 29. Review of the facility's policy titled, Storage of Medication, dated November 2020, showed:- The facility stores all drugs and biologicals in a safe, secure, and orderly manner;- Drugs and biologicals used in the facility are stored in locked compartments;- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner;- Compartments containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved.) The facility census was 25. Review showed the facility did not have a QAPI plan containing the necessary policies and protocols describing how they will identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurement. During an interview on 03/07/25 at 9:11 A.M., the Director of Nursing (DON) said she just started in January 2025, and found no documentation of a previous QAPI Plan. She was trying to get everything together but did not have anything in place yet.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 25. The facility did not provide a policy for a QAPI Plan or Performance Improvement Plans (PIPs). Review showed no documentation the facility maintained the minimum required documentation for a QAPI plan or PIPs. During an interview on 03/07/25 at 9:11 A.M., the Director of Nursing (DON) said there was no documentation the facility had a QAPI Plan or PIPs in place. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee meetings with the required members. The facility census was 25. The facility did not provide a policy or any documentation related to QAPI. Review showed no documentation the facility maintained the minimum required quarterly QAA meetings with the required members. During an interview on 03/07/25 at 9:11 A.M., the Director of Nursing (DON) said the facility did not have a QAPI policy and procedure. There was not a QA committee at this time. There was no documentation to review.

Inspectors wroteBased on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (ICIP) that included an antibiotic stewardship program. This deficient practice had the potential to affect all residents in the facility. The facility census was 25. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, showed: - Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program; - The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. Review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, showed: - Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to maintain appropriate infection control practices by not performing proper hand hygiene and glove changing techniques during wound care for two residents (Residents #5 and 13) out of two sampled residents and during catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #13) out of two sampled residents. The facility also failed to correctly screen five residents (Residents #4, #8, #13, #17, and #20) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents required by state regulation 19 CSR 20-20.100. The facility census was 25. The facility did not provide an infection control policy. Review of the facility policy titled, Catheter Care, Urinary, revised September 2014, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #2) out of one sampled resident. The facility census was 25. Review of the facility's policy titled, Dialysis Care, undated, showed: - Adequately assess resident needs and provide care goals which achieve the highest practicable level of care to residents with end stage renal disease receiving dialysis; - Risk factors related to potential for bleeding, alterations in fluid volume, potential for infection, alteration in nutrition, skin integrity, risk for adverse medication effects and psychosocial needs should be identified, assessed and interventions to manage addressed in the individualized care plan; [...]

Inspectors wroteBased on interview and record review, the facility failed to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medication to 14 days for two residents (Residents #8 and#11) out of four sampled residents. The facility census was 24. The facility did not provide a policy for PRN psychotropic medication use. 1. Review of Resident #8's March 2025 Physician Order Sheet (POS) showed: - Diagnoses of Alzheimer's disease (progressive mental deterioration), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with other behavioral disturbance, and cognitive communication deficit; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 30 opportunities with four errors made, for an error rate of 13.33%, which affected four residents (Residents #2, #5, #13, and #17) out of 16 sampled residents. The facility's census was 24. The facility did not provide a policy in regards to insulin administration. Review of the facility instruction sheet, Priming Insulin Pens Quick Reference, undated, showed: - Every insulin pen requires priming with each injection. Doing so ensures the correct amount of insulin is given to the patient. It removes air from the needle and cartridge that can collect during normal use and confirms the pen is working correctly. - Fiasp (insulin aspart - a rapid-acting insulin) dial two units when priming; [...]