17 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Prescott, AZ
1-star overall rating with 1-star inspections with abuse icon flag with 17 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
1045 Sandretto Drive, Prescott, AZ
(928) 778-4837
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
116
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Circle B Enterprises
Operator or chain grouping
Approved since
1985-06-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
29 facilities
Chain averages 2 overall / 3 health / 2 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.40
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.38
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
11,303
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 18.89% · Performance 23.47% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.95
Baseline 6.93% · Performance 7.25% · Measure score 1.95 · Achievement 1.95 · Improvement 0
Total nurse turnover
2.20
Baseline 63.83% · Performance 54.67% · Measure score 2.20 · Achievement 2.20 · Improvement 1.85
Adjusted total nurse staffing
2.77
Baseline 3.69 hours · Performance 3.87 hours · Measure score 2.77 · Achievement 2.77 · Improvement 0.34
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.97% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 143 · Observed rate 13.29% · Lower 95% interval 8.82% |
| Discharge to community | 58.02% |
50.57%
7.5 pts better
|
No Different than the National Rate · Eligible stays 136 · Observed rate 52.94% · Lower 95% interval 50.19% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.65% |
95.27%
2.4 pts better
|
Numerator 83 · Denominator 85 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 85 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 30 · Denominator 55 |
| Discharge mobility score | 56.36% |
50.94%
5.4 pts better
|
Numerator 31 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 85 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.25% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 7.59% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 69 |
| Staff flu vaccination coverage | 28.24% |
42%
13.8 pts worse
|
Numerator 24 · Denominator 85 |
| Discharge function score | 56.36% |
56.45%
0.1 pts worse
|
Numerator 31 · Denominator 55 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 97.83% |
96.28%
1.5 pts better
|
Numerator 45 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 47 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.6% |
97.1%
7.5 pts worse
|
93.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 83.3% · Q3 92.0% · Q4 97.7% · 4Q avg 89.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.0% |
94.6%
8.6 pts worse
|
95.5%
9.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.1%
0.5 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
4.2%
0.7 pts worse
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.8% · Q3 8.7% · Q4 4.9% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.3%
0.4 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.5% · Q3 2.8% · Q4 10.0% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.5% |
20.5%
4 pts worse
|
19.6%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 22.2% · Q3 19.4% · Q4 30.0% · 4Q avg 24.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
11.8%
8.2 pts worse
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 17.2% · Q3 20.8% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 39.8% |
14.5%
25.3 pts worse
|
16.3%
23.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 40.0% |
10.8%
29.2 pts worse
|
14.9%
25.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 45.8% · Q4 28.6% · 4Q avg 40.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.2%
1.5 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.9% · Q3 2.0% · Q4 2.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.1% |
20.5%
0.4 pts better
|
19.8%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 23.0% · Q3 18.7% · Q4 16.2% · 4Q avg 20.1% |
| Percentage of long-stay residents with pressure ulcers | 9.4% |
4.8%
4.6 pts worse
|
5.1%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 15.0% · Q3 8.8% · Q4 9.6% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.0% |
91.1%
31.1 pts worse
|
81.7%
21.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.4% · Q2 57.0% · Q3 68.5% · Q4 65.6% · 4Q avg 60.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.7% |
10.7%
18 pts worse
|
12.0%
16.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.7% · Observed 28.8% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.1%
0.5 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 2.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.8% |
87.3%
24.5 pts worse
|
79.7%
16.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.2% |
24.6%
9.6 pts worse
|
23.9%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.2% · Observed 32.2% · Expected 22.5% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-04-25
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-04-25
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-25
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-04-25
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-04-25
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-25
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-25
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-25
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-25
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-25
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-04-25
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-02-18
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-15
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-02-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-18
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-02-18
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-15
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-15
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-02-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-28
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-02-28
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-02-28
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-02-28
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-02-28
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-02-28
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-02-28
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-02-28
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-02-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-02-28
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-02-28
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-25
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-30
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-30
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-30
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-12
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-12
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-12
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-12
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-12
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-12
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-12
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2025-04-12
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-12
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-22
Health
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.
Corrected 2023-05-15
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-05-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-15
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-15
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-15
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-05-15
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-05-15
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-05-15
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-05-15
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-05-15
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-05-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-15
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-15
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-15
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-05-15
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-05-15
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-05-15
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-02-21
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-02-21
Health
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.
Corrected 2022-02-21
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-02-21
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-02-21
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-02-21
Health
Respond appropriately to all alleged violations.
Corrected 2022-02-21
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-02-21
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-02-21
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-02-21
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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