Baptist Homes Of Arcadia Valley

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

CMS has not published payroll-based (PBJ) staffing hours for this facility yet — this can happen for newer, hospital-based, or recently-certified homes. It can also mean the home simply did not file, which CMS does not distinguish in this data, so treat the gap as unexplained rather than benign. Staffing is one of the three parts of the CMS star rating; where it’s missing, weigh the independent health-inspection score most, and ask the facility directly about its nurse-to-resident ratios and weekend RN coverage.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

• Potential for harm · F2025-03-07 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — the official record, unedited, may be distressing

  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. She was trying to get everything together but did not have anything in place yet.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-03-07 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — the official record, unedited, may be distressing

  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. 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. The facility was currently trying to get everything in place.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-03-07 · tag F0868 — widespread
  Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
  What the surveyor found here — the official record, unedited, may be distressing

  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. There was no documentation to review.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-03-07 · tag F0881 — failed to use antibiotics responsibly — widespread
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. 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. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship; - As part of the facility antibiotic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-07 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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: - The purpose of this procedure is to prevent catheter-associated urinary tract infections; - Place the clean equipment on the bedside stand or overbed table; - Wash and dry your hands thoroughly; -…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-07 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; - An individual care plan should be developed and followed in coordination with the comprehensive assessment. 1. Review of Resident #2's Physician's Order Sheet (POS), dated March…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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; - An order for lorazepam (an antianxiety medication) 0.5 milligram (mg) by mouth every two hours PRN for anxiety, dated 02/25/25, with no stop date; - The facility failed to provide a 14 day stop date order for the lorazepam PRN order. 2. Review of Resident #11's March 2025 POS showed: - Diagnoses of mild cognitive…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-07 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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; - Lispro (Humalog - a rapid acting insulin) dial two units when priming, recommended to hold the dose button down five second when priming. Review of the Fiasp Flex Touch Pen Instructions, revised July 2023, showed: - To prime the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 26 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

What families pay in MO