Prescott Valley Nursing & Rehabilitation

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

sitting there and when the staff member looked up, the resident was shutting the neighbor's door. According to the note, the neighbor came out very upset and stated that this had happened at least three previous times. The note stated that a social worker attempted to talk to the resident but she got very upset and refused to listen. The note indicated that the nurse convinced the resident to stay away from the neighbor's door and was pleasant for the rest of the shift. Review of the facility investigator's (Social Worker/staff #56) memo dated August 17, 2025 documented that according to resident #63, a resident from across the hall had wandered into her room and slammed the door. Additionally, the memo indicated that resident #63 shared that the other resident would sit outside her room to stare at her which frightened her. The memo noted that staff #56 informed resident #63 to notify staff when incidents occur so they can address it. The memo noted that resident was educated that she needed to press the call light and staff would intervene as

they see it happen. An interview with a Certified Nursing Assistant (CNA/staff #50) was conducted on August 19, 2025 at 4:08 a.m. Staff #50 stated that resident #22 suffered from dementia, had a habit of wandering, and sitting in the hallway, and talking in the hallway. During an interview with a Registered Nurse (RN/staff #29) conducted on August 19 2025 at 8:10 a.m., staff #29 stated resident #22 had good and bad days with some cognitive impairment. The RN described the resident as loud, boisterous who wanders the hall. According to staff #29, she heard that resident #22 had gone into another resident's room and that resident was unhappy. Staff #29 said that the incident happened approximately 2-weeks ago. An

interview with the Director of Nursing (DON/staff #14) was conducted on August 19, 2024 at 1:28 p.m. Staff #14 stated that her expectation is that allegations of abuse are reported immediately. This is important in order to take the risk factor away. The DON said that the staff should have reported it immediately and removed the resident from that situation. Additionally, staff #14 stated that residents should not go into another resident's room without permission. The DON noted that resident #22 liked to walk in the hallway.

Furthermore, she commented that they encouraged resident #63 to use the call light to deter similar situations. Staff #14 stated that given that there was a progress note related to the event, the likelihood that

it happened should have been relayed to her. The facility policy on Abuse Prevention and Prohibition Program revised October 24, 2022 revealed that facility staff are mandatory reporters. The policy noted that facility staff members will report known or suspected instances of abuse to the Administrator, or his/her designee. Per the policy, each resident has the right to be free from abuse. Additionally, the policy indicated that staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, or mistreatment. Review of the facility policy on Resident Rights revised August 2020 indicated that all residents have a right to a dignified existence. Additionally, the policy noted that residents have the right to voice grievances and have the facility respond to those grievances in a prompt manner.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Prescott Valley Nursing & Rehabilitation

3380 North Windsong Drive Prescott Valley, AZ 86314

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

abuse to occur. The facility policy on Abuse Prevention and Prohibition Program revised October 24, 2022 stated that each resident has the right to be free from abuse. The policy indicated that policy served to ensure that the facility establishes, operationalizes, and maintains an abuse prevention and prohibition program designed to protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse. Additionally, the policy indicated that staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, or mistreatment. The policy noted that the facility promptly and thoroughly investigates reports of abuse. The policy also highlighted the steps that may be taken to investigate an allegation of abuse.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Prescott Valley Nursing & Rehabilitation

3380 North Windsong Drive Prescott Valley, AZ 86314

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

she informed staff #56 (Social Worker). According to staff #29, the Social Worker (staff #56) spoke with resident #63 immediately. Following the discussion between staff #56 and resident #63, staff #29 was told that resident #22 had to be watched. The RN said that someone had seen resident #22 coming out of resident #63's room. Staff #29 stated that if resident #63 had expressed to a staff that an incident scared and intimidated her then yes, it would be qualified as abuse. According to staff #29, she heard that resident #22 had gone into another resident's room and that resident was unhappy. Staff #29 said that the incident happened approximately 2-weeks ago. The RN noted that reporting and investigating allegations of abuse is important so that residents trust and know that their rights are not being abused and that they have the right to not feel threatened. An interview with a Social Worker (staff #56) was conducted on August 19, 2025 at 9:44 a.m. Staff #56 stated that it is important that the facility prevents residents from being abuse.

The Social Worker said that the impact of residents being subjected to abuse is that the residents might get hurt and injured. Staff #56 admitted that resident #63 told her in passing on August 8, 2025 about residents coming up and sitting by her door. The Social Worker said that resident #63 told her that she was frightened and that she responded by asking resident #63 if she activated her call light. She relayed that the resident seemed frustrated. Staff #56 said that reporting and investigating abuse is important to make sure that residents are not in imminent danger. Investigations help determine what happened and see if there are any witnesses. An interview with the Director of Nursing (DON/staff #14) was conducted on August 19, 2024 at 1:28 p.m. Staff #14 stated that her expectation is that allegations of abuse are reported immediately. This is important in order to take the risk factor away. The DON said that the staff should have reported it immediately and removed the resident from that situation. According to staff #14, she first heard about the abuse allegation when the member of the survey team informed them about the allegation. She noted that it was not appropriate that the alleged incident was not reported to her and the administrator.

During an interview with the Administrator (staff #333) conducted on August 19, 2025 at 2:09 p.m., staff #333 stated that allegations of abuse should be reported to him as soon as it happens. This is important in order to ensure resident is safe and to start the investigation. The impact of not reporting is that there is a potential for abuse to occur. The Administrator said that if the incident was witnessed then it should have been brought to their attention. The facility policy on Abuse Prevention and Prohibition Program revised October 24, 2022 revealed that facility staff are mandatory reporters. The policy noted that facility staff members will report known or suspected instances of abuse to the Administrator, or his/her designee. Per

the policy, each resident has the right to be free from abuse. Additionally, the policy indicated that staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, or mistreatment. The policy indicated that the facility will report allegations of abuse immediately but no later than 2-hours after discovery. Review of the facility policy on Resident Rights revised August 2020 indicated that all residents have a right to a dignified existence. Additionally, the policy noted that residents have the right to voice grievances and have the facility respond to those grievances in a prompt manner.

Event ID:

Facility ID:

If continuation sheet