Haven Of Flagstaff
800 West University Avenue, Flagstaff, AZ 86001 · For profit - Corporation · 83 certified beds · (928) 779-6931 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,098 in federal fines (most recent 2025-03-14)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.9% | 10.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.4% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.8% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.1% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.6% | 3.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.3% | 2.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 8.9% | 12.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.5% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.1% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.1% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 10.6% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.1% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.1% | 87.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.9% | 23.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.2% | 10.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.63 | 1.47 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.57 | 1.42 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
56.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 301 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 129 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.7%CMS range 50.3–62.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 8.1–13.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 72.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 67.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 5.0–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.00 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 83 beds and averages 77.9 residents a day — about 94% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.09 hrs/resident/day on weekends vs 3.45 on weekdays — 11% thinner on weekends. RN hours go from 0.83 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2025-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident (#10) was free from a preventable accident that resulted in serious injury. The deficient practice could lead to further instances of accidents resulting in injuries to residents. Findings include: Resident #10 was admitted on [DATE], with diagnoses that included acute kidney failure, cardiac murmur, repeated falls, difficulty in walking, and age-related osteoporosis. A quarterly minimum data set (MDS) assessment dated [DATE], revealed that the resident had a brief interview for mental status (BIMS) score of 4, indicating the resident had severe cognitive impairment. A physician order dated March 22, 2025, indicated for a right ankle boot for possible calcaneal stress fracture, and to repeat right ankle x-ray the week of April 7, 2025. A care plan dated April 16, 2025, revealed that the resident had or was at risk for having functional mobility deficits or functional mobility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, clinical record reviews, facility documentation, and facility policies, the facility failed to ensure that medications were not diverted for two residents (#13 and #15). This deficient practice could result in Controlled Substance being diverted and not being available to residents as prescribed.Findings Include: -Regarding Resident #15:Resident #15 was admitted to the facility on [DATE], with diagnoses of hyperlipidemia, Gastro-Esophageal Reflux Disease (GERD), and heart failure.A care plan initiated on November 13, 2025, revealed a focus area for the Resident #15 to be on Opiate medications related to post-surgical. The care also revealed a goal to be free of adverse reactions related to opiate medication and an intervention to administer medication as needed. A review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-14 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one of five sampled resident (#136) were safe to self-administer medication. The deficient practice could result in a medication overdose. Findings Include: Resident #136 was admitted on [DATE] with diagnosis of dysphasia, chronic obstructive pulmonary disease, bipolar disorder, depression, anxiety and pressure ulcer. The admission Assessment Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A Care Plan dated March 07, 2025 revealed no indication of a focus for medication self-administration. Review of the clinical record revealed no evidence of a medication self-administration order. Review of the clinical record revealed no evidence of a medication self-administration assessment. During an initial observation of resident #136's room was conducted on March 11, 2025 at 12:01 p.m., there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 5 sampled residents (Resident # 284) was free from abuse by another resident (#183). The deficient practice could result in other residents being abused. Findings include: -Regarding Resident #183 Resident #183 was admitted to the facility on [DATE]. 2024 with diagnoses of dementia, muscle weakness, and history of falling. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2 indicating severe cognitive impairment. The assessment did not indicate any behaviors. A comprehensive care plan dated January 18, 2024, revealed that Resident #183 had communication problems due to dementia, and impaired cognitive function due to dementia. There was no evidence of a focus on interventions related to behaviors in the care plan. An alert charting progress note dated January 26, 2024, revealed that the resident was adjusting well to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-14 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to implement their abuse policy involving an allegation of abuse with two residents (#284 and #183) to law enforcement. The deficient practice could result in the appropriate State Agencies not being notified and allegations of abuse not being thoroughly investigated. Findings include: -Regarding Resident #183 Resident #183 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and history of falling. A comprehensive care plan dated January 18, 2024 revealed that Resident #183 had communication problems due to dementia. The care plan also revealed that she had impaired cognitive function due to dementia. -Regarding Resident #284 Resident #284 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, visual hallucinations, and urinary tract infection. Review of the facility's investigation report revealed that on February 26, 2024, Resident #284…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-14 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure an allegation of resident (#183) to resident (#284) abuse was reported to all applicable state agencies. The deficient practice could result in further allegations of abuse not being reported. Findings include: -Regarding Resident #183 Resident #183 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and history of falling. A comprehensive care plan dated January 18, 2024 revealed that Resident #183 had communication problems due to dementia. The care plan also revealed that she had impaired cognitive function due to dementia. -Regarding Resident #284 Resident #284 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, visual hallucinations, and urinary tract infection. Review of the facility's investigation report revealed that on February 26, 2024, Residents #284 and #183 were found to be in in an altercation, with an allegation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-14 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated, when stored for residents' use. The deficient practice could increase the risk of foodborne illness. Findings include: -Regarding food labeling, dating and storage An initial kitchen observation was conducted on March 11, 2025 at 11:10 a.m. with the Dietary Manager (DM/staff #43). During the observation, the following items were found in the refrigerator not labelled and dated: -An apple juice in a clear pitcher with the lid -An orange juice in a clear pitcher with the lid -Cranberry juices in clear pitchers with lid -Roasted potatoes stored in a stainless-steel container and covered with the plastic wrap An interview was conducted on March 13, 2025 at 11:08 a.m. with the Dietary Manager (DM/staff #43). The DM stated that unlabeled prepared food have the potential risk for foodborne illness. Additionally, during the interview with the DM (staff #43) conducted on March 11, 2025 at 11:10 a.m., staff #43 explained that the unlabeled apple juice, orange juice,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-14 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to maintain medical records that are complete and accurate in accordance with professional standards for 2 of 15 sampled residents (# 183, 284). The deficient practice could result in records that do not accurately and completely reflect the care and services provided to residents. Findings Include: -Regarding Resident #183 Resident #183 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and history of falling. A comprehensive care plan dated January 18, 2024 revealed that Resident #183 had communication problems due to dementia. The care plan also revealed that she had impaired cognitive function due to dementia. A late entry change of condition summary note dated February 26, 2024 at 11:44 p.m., revealed that the resident was adjusting well to a new room. However, there was no evidence in the progress note regarding what the change of condition was or why the change of room was necessary.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-23 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#1 and #2) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Regarding resident #1 Resident #1 was admitted on [DATE] with diagnosis including displaced intertrochanteric fracture of the right femur, low back pain, unsteadiness on feet, hypertension, unspecified glaucoma, major depressive disorder-recurrent, insomnia, type 2 diabetes with neuropathy, muscle wasting and atrophy, abnormalities of gait and mobility, osteoporosis, repeated falls and urinary tract infection. A review of the admission MDS (minimum data set) dated January 6, 2021 revealed a BIMS (brief interview of mental status) score of 00, indicating severe cognitive impairment. -Regarding resident #2 Resident #2 was admitted on [DATE] with diagnosis including unspecified fracture of right femur, repeated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to submit a 5-day written investigation summary regarding physical altercation between 2 residents (#1 and #2). The deficient practice could result in allegations of abuse not being investigated. Findings include: -Regarding resident #1 Resident #1 was admitted on [DATE] with diagnosis including displaced intertrochanteric fracture of the right femur, low back pain, unsteadiness on feet, hypertension, unspecified glaucoma, major depressive disorder-recurrent, insomnia, type 2 diabetes with neuropathy, muscle wasting and atrophy, abnormalities of gait and mobility, osteoporosis, repeated falls and urinary tract infection. A review of the admission MDS (minimum data set) dated January 6, 2021 revealed a BIMS (brief interview of mental status) score of 00, indicating severe cognitive impairment. -Regarding resident #2 Resident #2 was admitted on [DATE] with diagnosis including unspecified fracture of right femur,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that one resident (#3) received care for pressure ulcers consistent with professional standards when observed wound care assessments were not completed on a weekly basis. This had the potential for pressure ulcers for resident #3 to worsen. Findings include: Resident #3 was admitted on [DATE] with diagnosis including venous insufficiency (chronic-peripheral), pressure ulcer of the left heel (unstageable), pressure ulcer of the right heel (unstageable), acute posthemorragic anemia and cellulitis of the left lower limb. A review of the discharge MDS (minimum data set) dated March 10, 2021 revealed no BIMS (brief interview of mental status) score. A review of the physician orders revealed orders for daily wound care to both right/ left heels and posterior right/ left calf. Orders were further observed for physical and occupational therapy. An order dated March 10, 2021 was also observed for a consult for heel debridement. A review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2023-12-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (#71) was free from abuse of another. The deficient practice could result on resident being physically and psychosocially harmed by other residents. Findings include: Resident #71 was admitted on [DATE] with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness. The minimum data set (MDS) assessment dated [DATE] include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact. The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to provide evidence that the an allegation of abuse for one resident (#71) was thoroughly investigated and results of the investigation was reported to the State Agency within 5 working days of the incident. The deficient practice could result on further abuse of residents and appropriate actions not taken. Findings include: Resident #71 was admitted on [DATE] with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness. The minimum data set (MDS) assessment dated [DATE] include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact. The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-05 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel record review, staff interview, and the job description, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in not providing activities that meet the physical and psychosocial needs of the residents. Findings include: Review of the personnel file for the Activity Manager (staff #95) revealed staff #95 was hired on July 30, 2021 as a CNA (Certified Nursing Assistant) and promoted to the Activity Manager on June 10, 2023. Continued review of the file did not reveal documentation that staff #95 met the qualifications for the Activity Manager. Review of the 2016 Employee Job Description for Haven Health Group, version 0916 revealed the Activity Manager works under the direction of the Executive Director and is an active member of the Interdisciplinary Care Team. The Activity Manager directs the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion of the activity's component of the comprehensive assessment along with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-05 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure that a resident (#39) had been assessed to self adminster medications. The deficient practice could result in resident not receiving medications needed to maintain or improve their physical health. Findings included: The resident (#39) was admitted to the facility on [DATE] with diagnoses that include: orthostatic hypotension, hypo-osmolality and hyponatremia, other specified diseases of blood and blood-forming organs, and acute kidney failure, unspecified. A review of the physician's orders revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ Give 3 tablet by mouth two times a day for hypokalemia until 10/15/2023. Review of the MDS (minimum data set) dated September 17, 2023 revealed a BIMS (brief interview of mental status) score of 14 indicating cognitive intactness. On October 02, 2023 at approximately 2:18 PM during the initial screening process a small clear cup containing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure that alleged violations involving abuse were reported within required timeframe for one resident (#13). This resulted in the allegation of abuse not being investigated. Findings Include: Resident #13 admitted to the facility on [DATE] with diagnoses that included sepsis, scoliosis, osteoporosis, acute kidney failure, and acute respiratory failure. In her current care plan there is a goal with appropriate interventions related to her limited physical mobility related to contracture. In a 30 day look back period Resident #13 needed extensive assistance from staff when transferring (moving from bed to wheelchair and vice versa for example) with one occasion of full staff performance September 22, 2023 at 4:00 PM. During an interview conducted on October 2, 2023 at 01:56 PM, Resident #13 said she had dignity concerns, and stated that a Certified Nursing Assistant (CNA) had put her in her wheelchair…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-05 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that a PASRR Level 2 referral was completed for one resident (#30). The deficient practice could lead to residents not receiving needed care and services. Findings include: Resident #30 was admitted to the facility on [DATE] with diagnosis of Dementia, Unspecified severity with mood disturbance and Major Depressive Disorder, single episode, severe with psychotic features. The resident had a PASRR Level 1 and 2 at that time. A review of the resident record revealed that resident #30 readmitted to the facility with a new diagnosis of Schizoaffective Disorder, unspecified. Further review of the clinical record revealed a completed level 1 PASRR dated February 2, 2021. The level 1 PASRR revealed that the resident had serious mental illness and a level 2 PASRR should be completed. No evidence of any further PASRR documentation was found in the resident clinical record. The facility has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-05 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I was updated appropriately for one resident (#47). The deficient practice could result in specialized services not being identified and provided to residents. Findings include: Resident #47 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, psychoactive substance dependence,, and chronic obstructive pulmonary disease with acute exacerbation. A Level I PASRR screening completed on August 11, 2023 included the attending physician had certified, prior to admission, that the resident would require less than 30 calendar days of nursing facility services and that the nursing facility must update the Level I at such a time it appeared the resident's stay would exceed 30 days. However, review of the clinical record did not indicate an updated PASRR had been completed. Review of the admission Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-05 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure rehabilitation services were provided for one resident (#16) as ordered by the physician. The deficient practice could result in resident not receiving rehabilitation services needed to maintain or improve their physical health. Findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses including non-insulin dependent diabetes mellitus, coronary artery disease, and left below knee amputation. Review of record of Provider Progress Notes dated December 5, 2022 for resident #16 revealed Patient has great difficulty walking and standing, requires wheelchair, difficult to leave assisted living for appointments so seen in assisted living today. Denies other pedal or ankle concerns at this time. Denies recent falls or trauma. Feeling well, denies nausea/vomiting/diarrhea/ Review of record of Provider Progress Notes dated June 22, 2023 for resident #16 revealed Patient has great…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-08-18 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, manufacturer manual, and policy reviews, the facility failed to ensure the dishwasher sanitation was monitored, kitchenware was clean and dry, and that the electrical cord and outlets above the tray line were clean. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding dishwasher sanitation During the initial kitchen observation conducted on August 15, 2022 at 10:03 a.m., a staff member was observed testing the chemical dishwasher machine. The test indicated that the sanitizer level was low. It should be between 50-100 parts per million (ppm). The dishwasher (staff #97) adjusted the bucket tubing and tested the chemicals twice before it yielded the appropriate result. He said they will get a technician to service the dishwasher machine. A second observation of the kitchen was conducted on August 17, 2022 at 8:50 a.m. During this observation, the dishwasher chemical resulted in a reading between 25-50 ppm. Staff #97 ran the machine again then tested a second time and the result was 50 ppm. A third…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure an allegation of resident (#183) to resident (#184) abuse was reported timely to the State Agency (SA). The deficient practice could result in further allegations of abuse not being reported timely. Findings include: -Resident #183 was admitted on [DATE] with diagnoses that included urinary tract infection, hearing loss, and a stage 1 pressure ulcer. -Resident #184 was admitted on [DATE] with diagnoses that included an open wound to the left lower leg, dementia without behavioral disturbance, and type 2 diabetes mellitus. Review of the facility reportable event revealed that a resident to resident incident occurred on June 25, 2022 involving resident #183. The incident was reported to the SA on June 27, 2022. The intake detail revealed that while the DON (Director of Nursing) was reading the facility risk management report at 11:25 a.m. on June 27, 2022, an incident of alleged resident to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-18 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a discharge MDS (Minimum Data Set) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) System within the required time frame for one resident (#2). The deficient practice could result in lack of resident specific information for quality measure purposes. Findings include: Resident #2 was admitted on [DATE] with diagnoses that included dementia, cholecystitis, hemiplegia and hemiparesis following a cerebral infarction. Review of the clinical record revealed a Discharge assessment dated [DATE] that the resident was discharged to the community. However, review of the clinical record and the CMS System did not reveal a discharge MDS assessment had been submitted to the CMS System. An interview was conducted with the MDS coordinator (staff #79) and her supervisor (staff #126) on August 18, 2022 at 3:12 PM. Staff #79 stated that when a resident is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure one resident's (#68) Minimum Data Set (MDS) assessment was accurate. The sample size was 23. The deficient practice could result in inaccurate discharge tracking information. Findings include: Resident #68 was admitted to the facility on [DATE] with diagnoses that included diabetes and hip fracture. Review of a progress note dated 6/3/2022 revealed the resident was discharged to the resident's daughter's home. However, review of the discharge MDS assessment dated [DATE] revealed the resident was discharged to an acute hospital. In an interview conducted with the MDS corporate support (staff #126) on 8/17/2022 at 12:15 PM, staff #126 said the progress note states the resident was discharged home and the discharge MDS assessment states the resident was discharged to an acute hospital. Staff #126 stated the MDS assessment was incorrect and that a correction would be made. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-18 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, facility documentation, and policy reviews, the facility failed to ensure that activities were provided according to one resident's (#16) preferences. The sample size was 4. The deficient practice could result in residents not having the opportunity to participate in activities of their choice. Findings include: Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included COVID-19, acquired absence of right fingers and left leg above the knee, chronic kidney disease with dependence on renal dialysis, and muscle weakness. The activity data collection dated March 3, 2022 revealed the resident found it very important to be involved with favorite activities which included movies and television. The assessment also revealed the resident's participation in activities fluctuated due to dialysis and fatigue. The quarterly activity participation review dated March 3, 2022 revealed that the resident listed several favorite…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$13,098 in federal fines across 1 penalty.
- $13,098 — penalty dated 2025-03-14
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to HAVEN HEALTH — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.7 | +0.3 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 19 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SAMUELIAN, ROBERT | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2013 |
| SAMUELIAN, SPENCER | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/24/2025 |
| SAMUELIAN, STEPHEN | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2013 |
| SEASTRAND, JASON | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2013 |
| WEST, CHRISTIAN | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2013 |
| HAVEN ARIZONA REAL ESTATE, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 02/01/2013 |
| HAVEN FLAGSTAFF REAL ESTATE LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 02/01/2013 |
| HAVEN REAL ESTATE PARTNERS, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 02/01/2013 |
| HEALTH GROUP MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2013 |
| TERNION PHYSICIAN GROUP, PLLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| ESPINOSA, STEPHANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/14/2024 |
| FIGUEROA-DIAZ, VICENTE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| FRAGOSO, LINDSAY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/10/2021 |
| LONGHURST, STOCK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/15/2020 |
| MCCULLOUGH, ERIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| MILLER, CRYSTAL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/27/2023 |
| ROBERTSON, BRETT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2013 |
| SCIARA, PATRICK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2021 |
| SMITH, WENDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/23/2015 |
CMS files one row per role, so the 43 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $722K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in AZ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arizona Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 035091. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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