Baptist Homes of Arcadia Valley

In the surveyor’s words

From the most serious findings on record at Baptist Homes of Arcadia Valley, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 13, 2026

  Based on observation, interview, and record review, the facility failed to ensure staff provided appropriate supervision for a cognitively impaired resident (Resident #1) who was at risk of falling when Certified Nursing Assistant (CNA) A, left the resident unattended in a drained whirlpool tub with the whirlpool door open. The lack of supervision resulted in the resident falling, being airlifted to a hospital where Resident #1 was admitted for four days, having pain, and bruising to the right outer hip. The facility census was 20. […]

• No harm, potential for more than minimal, widespreadF865Mar 7, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF867Mar 7, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF868Mar 7, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF881Mar 7, 2025

  Based 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. […]