Cycle 1
Health 2023-11-10 · Fire 2023-11-10
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Prescott Valley, AZ
Prescott Valley Nursing & Rehabilitation
3-star overall rating with 2-star inspections with abuse icon flag with $8,278 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3380 North Windsong Drive, Prescott Valley, AZ
(928) 775-0045
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
53
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
1997-10-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.44
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.13
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
0.42
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
4.20
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,344
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0041
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.67
Baseline 19.05% · Performance 18.34% · Measure score 6.67 · Achievement 6.67 · Improvement 3.01
Healthcare-associated infections
6.81
Baseline 6.04% · Performance 5.80% · Measure score 6.81 · Achievement 6.81 · Improvement 1.77
Total nurse turnover
4.07
Baseline 43.08% · Performance 47.06% · Measure score 4.07 · Achievement 4.07 · Improvement 0
Adjusted total nurse staffing
2.49
Baseline 4.57 hours · Performance 3.79 hours · Measure score 2.49 · Achievement 2.49 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.26% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 254 · Observed rate 11.81% · Lower 95% interval 9.35% |
| Discharge to community | 63.37% |
50.57%
12.8 pts better
|
Better than the National Rate · Eligible stays 247 · Observed rate 63.56% · Lower 95% interval 58.72% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.7% |
95.27%
2.6 pts worse
|
Numerator 165 · Denominator 178 |
| Falls with major injury | 1.12% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 178 |
| Discharge self-care score | 63.04% |
53.69%
9.4 pts better
|
Numerator 87 · Denominator 138 |
| Discharge mobility score | 68.12% |
50.94%
17.2 pts better
|
Numerator 94 · Denominator 138 |
| Pressure ulcers or injuries, new or worsened | 1.69% |
2.29%
0.6 pts better
|
Numerator 3 · Denominator 178 · Adjusted rate 2.32% |
| Healthcare-associated infections requiring hospitalization | 5.8% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 3.14% · Lower 95% interval 3.58% |
| Staff COVID-19 vaccination coverage | 22.9% |
8.2%
14.7 pts better
|
Numerator 30 · Denominator 131 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 67.39% |
56.45%
10.9 pts better
|
Numerator 93 · Denominator 138 |
| Transfer of health information to provider | 93.94% |
95.95%
2 pts worse
|
Numerator 31 · Denominator 33 |
| Transfer of health information to patient | 97.14% |
96.28%
0.9 pts better
|
Numerator 136 · Denominator 140 |
| Resident COVID-19 vaccinations up to date | 6.17% |
25.2%
19 pts worse
|
Numerator 5 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.9% |
94.6%
0.7 pts worse
|
95.5%
1.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
2.1%
4.7 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 9.7% · Q3 3.7% · Q4 0.0% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
4.2%
2.5 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 10.7% · Q3 0.0% · Q4 4.2% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.3%
0.5 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
20.5%
5.4 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.7% · Q3 21.7% · Q4 25.0% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
11.8%
3 pts worse
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 14.3% · 4Q avg 14.8% · 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 | 9.4% |
14.5%
5.1 pts better
|
16.3%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
10.8%
3.1 pts worse
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 20.8% · Q3 9.1% · Q4 0.0% · 4Q avg 13.9% · 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 | 2.6% |
1.2%
1.4 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.7% |
20.5%
0.2 pts worse
|
19.8%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 14.4% · Q3 26.9% · Q4 11.8% · 4Q avg 20.7% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.8%
4.8 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.1%
8.3 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 98.9% · Q3 99.5% · Q4 99.5% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.1% |
10.7%
4.4 pts worse
|
12.0%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 14.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.1%
0.4 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.7% · Q4 1.2% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.4% |
87.3%
2.1 pts better
|
79.7%
9.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
24.6%
0.1 pts better
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 22.7% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-09 · Fire 2022-09-09
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-04-02 · Fire 2021-04-02
10 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-11-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-11-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-11-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-11-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-04
D · Potential for more than minimal harm
2022-09-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-09-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-11-14
E · Potential for more than minimal harm
2021-04-02
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-05-03
E · Potential for more than minimal harm
2021-04-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-05-03
E · Potential for more than minimal harm
2021-04-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-05-03
E · Potential for more than minimal harm
2021-04-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-05-03
D · Potential for more than minimal harm
2021-04-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-05-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-08-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-08-20
D · Potential for more than minimal harm
2025-08-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-20
G · Actual harm
2025-07-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-03-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-04-09
E · Potential for more than minimal harm
2023-11-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-12-22
E · Potential for more than minimal harm
2022-09-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-09
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-09-09
F608 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-09
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-09
F756 · Pharmacy Service Deficiencies
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 2022-10-31
D · Potential for more than minimal harm
2022-09-09
F758 · Pharmacy Service Deficiencies
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 2022-10-31
D · Potential for more than minimal harm
2022-09-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-10-31
D · Potential for more than minimal harm
2022-09-09
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-10-31
E · Potential for more than minimal harm
2021-04-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-04-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-04-02
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-04-02
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-04-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-04-02
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-04-02
F758 · Pharmacy Service Deficiencies
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 2021-04-26
D · Potential for more than minimal harm
2021-04-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-04-26
D · Potential for more than minimal harm
2021-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-04-26
B · Minimal harm
2021-04-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-04-26
Penalties and ownership
What sits behind the stars
$8,278
2025-07-11
Fine
Fine · fine $8,278
Fine
Ownership
Az Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Indigo Az Trust
5% Or Greater Indirect Ownership Interest · Organization
Amethyst Az Trust
5% Or Greater Indirect Ownership Interest · Organization
Garetz, David
Operational/Managerial Control · Individual
Garetz, David
Corporate Officer · Individual
Garland, Thomas
Operational/Managerial Control · Individual
Guthmiller, Trevor
Operational/Managerial Control · Individual
Nearby options
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Mountain View Manor
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
#2
Granite Creek Health & Rehabilitation Center
Prescott, AZ
2-star overall rating with 1-star inspections with abuse icon flag with 12 recent health deficiencies
#3
Prescott Village Nursing & Rehabilitation
Prescott, AZ
2-star overall rating with 1-star inspections with $8,278 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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