Cycle 1
Health 2024-01-25 · Fire 2024-01-25
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Prescott, AZ
Prescott Village Nursing & Rehabilitation
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
1030 Scott Drive, Prescott, AZ
(928) 778-2450
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
58
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
1988-05-19
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
0.54
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.63
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.02
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
2.54
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
2.73
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,273
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.96% · Performance 21.97% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.50
Baseline 7.34% · Performance 6.19% · Measure score 5.50 · Achievement 5.50 · Improvement 4.4
Total nurse turnover
0.91
Baseline 65.79% · Performance 60.00% · Measure score 0.91 · Achievement 0.9 · Improvement 0.91
Adjusted total nurse staffing
1.95
Baseline 3.72 hours · Performance 3.63 hours · Measure score 1.95 · Achievement 1.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.83% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 7.87% · Lower 95% interval 7.86% |
| Discharge to community | 68.93% |
50.57%
18.4 pts better
|
Better than the National Rate · Eligible stays 123 · Observed rate 73.98% · Lower 95% interval 61.21% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 99.03% |
95.27%
3.8 pts better
|
Numerator 102 · Denominator 103 |
| Falls with major injury | 1.94% |
0.77%
1.2 pts worse
|
Numerator 2 · Denominator 103 |
| Discharge self-care score | 77.5% |
53.69%
23.8 pts better
|
Numerator 62 · Denominator 80 |
| Discharge mobility score | 57.5% |
50.94%
6.6 pts better
|
Numerator 46 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 0.97% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 103 · Adjusted rate 1.6% |
| Healthcare-associated infections requiring hospitalization | 6.19% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 2.53% · Lower 95% interval 3.02% |
| Staff COVID-19 vaccination coverage | 3.64% |
8.2%
4.6 pts worse
|
Numerator 2 · Denominator 55 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 76.25% |
56.45%
19.8 pts better
|
Numerator 61 · Denominator 80 |
| Transfer of health information to provider | 65.22% |
95.95%
30.7 pts worse
|
Numerator 15 · Denominator 23 |
| Transfer of health information to patient | 98.7% |
96.28%
2.4 pts better
|
Numerator 76 · Denominator 77 |
| Resident COVID-19 vaccinations up to date | 3.33% |
25.2%
21.9 pts worse
|
Numerator 2 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
97.1%
2 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.9% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.3% |
94.6%
1.7 pts better
|
95.5%
0.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
2.1%
0.2 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 3.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.2%
4.2 pts better
|
11.4%
11.4 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 who lose too much weight | 8.6% |
5.3%
3.3 pts worse
|
5.4%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · Q4 0.0% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.2% |
20.5%
8.3 pts better
|
19.6%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 10.0% · Q4 15.4% · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
11.8%
5.2 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 5.0% · 4Q avg 6.6% · 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 | 18.8% |
14.5%
4.3 pts worse
|
16.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
10.8%
4 pts worse
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 15.0% · Q4 20.0% · 4Q avg 14.8% · 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 | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 10.3% |
20.5%
10.2 pts better
|
19.8%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 14.8% · Q3 14.1% · Q4 9.0% · 4Q avg 10.3% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.8%
3.1 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.1% |
91.1%
7 pts worse
|
81.7%
2.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.5% · Q2 86.1% · Q3 87.3% · Q4 79.3% · 4Q avg 84.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.1% |
10.7%
5.6 pts better
|
12.0%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.1% · Observed 4.5% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.1%
0.9 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.9% |
87.3%
4.4 pts worse
|
79.7%
3.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
24.6%
0.9 pts worse
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 19.8% · Expected 18.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-06 · Fire 2022-10-06
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-06-10 · Fire 2021-06-10
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-01-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-03-30
D · Potential for more than minimal harm
2024-01-25
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 2024-03-31
D · Potential for more than minimal harm
2024-01-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-31
D · Potential for more than minimal harm
2022-10-06
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 2022-11-21
D · Potential for more than minimal harm
2022-10-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-10-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-21
D · Potential for more than minimal harm
2021-06-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-07-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-27
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 2025-09-12
D · Potential for more than minimal harm
2025-05-06
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 2025-05-15
G · Actual harm
2025-03-25
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 2025-04-03
D · Potential for more than minimal harm
2025-03-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-25
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 2025-04-30
F · Potential for more than minimal harm
2024-01-25
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 2024-03-31
E · Potential for more than minimal harm
2024-01-25
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 2024-03-31
E · Potential for more than minimal harm
2024-01-25
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 2024-03-31
E · Potential for more than minimal harm
2024-01-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-01-25
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 2024-03-31
D · Potential for more than minimal harm
2024-01-25
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-01-25
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 2024-03-31
E · Potential for more than minimal harm
2022-10-06
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 2022-11-21
D · Potential for more than minimal harm
2022-10-06
F578 · Resident Rights Deficiencies
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 2022-11-21
D · Potential for more than minimal harm
2022-10-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-10-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-10-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-10-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-10-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-11-21
D · Potential for more than minimal harm
2022-10-06
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 2022-11-21
D · Potential for more than minimal harm
2022-10-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-21
E · Potential for more than minimal harm
2021-06-10
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 2021-07-26
E · Potential for more than minimal harm
2021-06-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-10
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 2021-07-26
E · Potential for more than minimal harm
2021-06-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-10
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-10
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-10
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 2021-07-26
D · Potential for more than minimal harm
2021-06-10
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 2021-07-26
D · Potential for more than minimal harm
2021-06-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-26
Penalties and ownership
What sits behind the stars
$8,278
2025-03-25
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
Dahn, Stephen
Operational/Managerial Control · Individual
Garetz, David
Operational/Managerial Control · Individual
Garetz, David
Corporate Officer · Individual
Gasser, Angela
Operational/Managerial Control · Individual
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