Inspection visit
Inspection
Citations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F758 - Medication Errors
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.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
FAQ · About this visit
Common questions about this visit
What happened during the March 7, 2025 survey of BAPTIST HOMES OF ARCADIA VALLEY?
This was a inspection survey of BAPTIST HOMES OF ARCADIA VALLEY on March 7, 2025. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BAPTIST HOMES OF ARCADIA VALLEY on March 7, 2025?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Inspect, test, and maintain automatic sprinkler systems."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.