Haven Of Globe
1100 Monroe Street, Globe, AZ 85501 · For profit - Corporation · 104 certified beds · (928) 425-5721 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2026
- 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
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
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) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 improved from 2 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 | 6.9% | 10.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 8.6% | 5.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.1% | 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 | 4.0% | 2.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 2.7% | 12.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 3.2% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.2% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.4% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.0% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.5% | 10.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 86.4% | 87.3% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 29.6% | 23.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.3% | 10.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.75 | 1.47 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.39 | 1.42 | 1.80 | worse |
‡ 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.
59.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 145 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 88.7% 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 71 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 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 59.2%CMS range 52.1–67.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.9–12.4 | 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 | 88.7% | 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 | 90.1% | 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 | 73.2% | 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 | 98.0% | 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 | 52.2% | 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 | 81.9% | 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 | 0.7% | 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 | 0.0% | 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 | 5.8%CMS range 3.5–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.10 | 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 104 beds and averages 77.6 residents a day — about 75% occupied, or roughly 26 beds typically open. It usually has some room. 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 2.83 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 2.42 hrs/resident/day on weekends vs 3.00 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.43 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% 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.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · Dcited before2026-07-01 · 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, resident and staff interviews, and policy review, the facility failed to protect one resident's (#96) rights to be free from staff-to-resident physical abuse. The deficient practice could result in residents being physically and emotionally harmed.Findings include:Resident #96 was admitted to the facility on [DATE], with a diagnosis that included encounter for palliative care, muscle spasms, atherosclerotic heart disease, malignant neoplasm of the cervix uteri, type 2 diabetes, hypertension, urinary incontinence, pressure ulcer of the sacral region, polyneuropathy, and generalized anxiety disorder.A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. A skin assessment dated [DATE], revealed that the resident did not have any skin impairments.Review of an alert charting progress note dated June 15, 2026, at 7:02 p.m. revealed that the resident had…
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 · D2026-07-01 · 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, resident and staff interviews, and policy review, the facility failed to ensure that the abuse policy was implemented following an incident of staff-to-resident abuse for one resident (#96). The deficient practice could result in residents being physically and emotionally harmed.Findings include:Resident #96 was admitted to the facility on [DATE], with a diagnosis that included encounter for palliative care, muscle spasms, atherosclerotic heart disease, malignant neoplasm of the cervix uteri, type 2 diabetes, hypertension, urinary incontinence, pressure ulcer of the sacral region, polyneuropathy, and generalized anxiety disorder.A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of an alert charting progress note dated June 15, 2026, at 7:02 p.m. revealed that the resident had activated her call light and that the certified nursing…
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 before2026-07-01 · 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, resident and staff interviews, and policy review, the facility failed to ensure that an incident of staff-to-resident abuse was reported within the required timeframe for one resident (#96). The deficient practice could result in residents being physically and emotionally harmed. Findings include:Resident #96 was admitted to the facility on [DATE], with a diagnosis that included encounter for palliative care, muscle spasms, atherosclerotic heart disease, malignant neoplasm of the cervix uteri, type 2 diabetes, hypertension, urinary incontinence, pressure ulcer of the sacral region, polyneuropathy, and generalized anxiety disorder.A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of an alert charting progress note dated June 15, 2026, at 7:02 p.m. revealed that the resident had activated her call light and that the certified nursing…
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 before2026-07-01 · 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, resident and staff interviews, and policy review, the facility failed to ensure that an incident of staff-to-resident abuse involving one resident (#96) was thoroughly investigated. The deficient practice could result in residents being physically and emotionally harmed.Findings include:Resident #96 was admitted to the facility on [DATE], with a diagnosis that included encounter for palliative care, muscle spasms, atherosclerotic heart disease, malignant neoplasm of the cervix uteri, type 2 diabetes, hypertension, urinary incontinence, pressure ulcer of the sacral region, polyneuropathy, and generalized anxiety disorder.A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of an alert charting progress note dated June 15, 2026, at 7:02 p.m. revealed that the resident had activated her call light and that the certified nursing assistant (CNA)…
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 before2026-06-10 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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 an observation, clinical record review, interviews, facility documentation and policies, and review of the State Agency (SA) database, the facility failed to protect the rights of 3 out of 18 sampled residents (#92, #93, #8) to be free from physical and verbal abuse by another resident. The deficient practice could result in further resident abuse.Findings included:-Regarding Resident #92 (alleged victim) and Resident #12 (alleged perpetrator) -Resident #92 was admitted on [DATE] with diagnosis that included Type 2 Diabetes Mellitus, dementia, and blindness of one eye.Review of clinical records dated December 21, 2022 through December 29, 2022 revealed that the resident had to be redirected back to her room several times, and wandered multiple times throughout residents' rooms and on various hallways. wandering required supervision.A daily skilled evaluation progress note dated December 30, 2022 revealed that the resident required supervision and guidance due to intermittent periods of wandering,…
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 beforedisputed · IDR2026-06-10 · tag F0609 — failed to report abuse allegations — patternTimely 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, interviews, documentation and policy, the facility failed to report the results of abuse allegation investigations to the state survey agency within 5 working days of the incident for 2 of 18 sampled residents (#12, #92) in accordance to state law. The deficient practice could result in facilities not submitting investigation reports to the State Survey agency within 5 working days.Findings include:Regarding Resident #92-Resident #92 was admitted on [DATE] with diagnosis that included Type 2 Diabetes Mellitus, dementia, and blindness of one eye. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status of 99, which indicated that the assessment could not be completed. A Staff Assessment for Mental Status assessment revealed Short-Term and Long-Term memory problems, and severely impaired daily decision making. Review of clinical records dated December 21, 2022 through December 29, 2022 revealed that the resident had to be redirected…
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 beforedisputed · IDR2026-06-10 · tag F0610 — failed to investigate and act on abuse reports — patternRespond 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, facility documentation and policy review, the facility failed to ensure that in response to allegations of abuse, that all alleged violations are thoroughly investigated, for 2 of 18 sampled residents (#12 and #92). The deficient practice could result in allegations of abuse not being thoroughly investigated. Findings include: -Regarding Resident #92 (alleged victim) and Resident #12 (alleged perpetrator): -Resident #92 was admitted on [DATE] with diagnosis that included Type 2 Diabetes Mellitus, dementia, and blindness of one eye. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status of 99, which indicated that the assessment could not be completed. A Staff Assessment for Mental Status assessment revealed Short-Term and Long-Term memory problems, and severely impaired daily decision making. Review of clinical records dated December 21, 2022 through December 29, 2022 revealed that the resident had to be…
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 · E2026-06-10 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 the facility assessment, facility documentation, interviews, and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving the appropriate care to maintain safety, and the highest practicable physical, mental, and psychological well-being as determined by resident assessments and individual plans of care.Findings include:The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for all four quarters in 2025, and the first quarter of 2026. The facility assessment reviewed on June 9,2026, revealed the facility was licensed to provide care for 104 residents, had an average daily census of 78-85, and had an average number of 3-6 weekday admissions and 1-2 weekend admissions, and 2-5 weekday discharges and 0-3 weekend discharges. Staffing plan included the following:-full time Director of Nursing (DON)-full…
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 · E2026-06-10 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
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, staff interviews, and policy review, the facility failed to ensure that drugs and biologicals were stored, secure, and inaccessible to unauthorized staff and residents in accordance with facility policy, state, and federal laws for four of eighteen sampled residents (#5, #22, #69, #89). The universe was seventy-one. The deficient practice could lead to medications being incorrectly administered or accidentally ingested by a resident. Findings Include: -Regarding Resident #5 Resident #5 was admitted on [DATE] with diagnosis including bipolar disorder, current episode-depressed, dementia-unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, psychosis not due to a substance or known psychological condition, schizoaffective disorder, essential hypertension, edema, dermatitis, cellulitis and pruritis. A review of the annual MDS (minimum data set) dated March 23, 2026 revealed a BIMS (brief interview of mental status) score of 99, indicating 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 before2026-06-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 record review, staff interviews, review of facility documents and policy, the facility failed to ensure one out of eighteen sampled residents (#47) received treatment and care related to insulin and blood pressure medications in accordance with the provider's order, professional standards of practice and the resident's comprehensive person-centered care plan. The deficient practice could place the residents' health at risk.Findings include:Resident #47 was readmitted to the facility on [DATE], with diagnoses that included essential hypertension, type 2 diabetes mellitus, and end stage renal disease requiring hemodialysis treatment. The Resident's care plan revealed that the Resident had diabetes mellitus and hypertension. The goal was for the Resident to have no complications related to his diagnoses of diabetes and hypertension. The interventions included for the staff to administer medications for diabetes and anti-hypertensive as ordered by the doctor, obtain fasting blood sugar test as ordered by…
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 12 citations
- Potential for harm · D2026-06-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 record review, staff interviews, observations, and review of facility policies and procedures, the facility failed to ensure that 2 out of 18 sampled residents (#1 and #2) received appropriate treatments and services to prevent urinary tract infections. The deficient practice could lead to a high risk of CAUTI (catheter-associated urinary tract infections), contamination transfer, tube obstruction or resident injury. Findings Include: -Regarding Resident #1 Resident #1 was admitted on [DATE] with diagnosis including type 2 diabetes mellites without complications, encephalopathy, end stage renal disease, bacteriuria, paroxysmal atrial fibrillation, dependence on renal dialysis, urinary tract infection, systemic inflammatory response syndrome of non-infectious origin, epilepsy, dementia with other behavioral disturbance, and obstructive and reflux uropathy. A review of the 5-day MDS (minimum data set) dated May 17, 2026 revealed a BIMS (brief interview of mental status) score of 6, indicated that 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 · Ecited before2025-04-02 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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, interviews, facility documentation and policy review, the facility failed to ensure four residents (#50, #150, #100 and #250) were free from abuse from other residents (#100, #250, #200). The deficient practice could lead to other resident to resident altercations which could result in harm. Findings include: Resident #100 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disburbances, chronic kidney disease, alcohol abuse and major depressive disorder. Review of the MDS (Minimum Data Set) dated August 14, 2022 reveals a BIMS (Brief Interview for Mental Status) score of 99, indicating resident #100 to be severely cognitively impaired. Resident #250 was admitted to the facility on [DATE] with a diagnosis of vascular dementia with behavioral disturbance and post-traumatic stress disorder. Review of the MDS dated [DATE] reveals a BIMS score of 99, indicating resident #250 to be severely cognitively impaired. On the morning of March 13, 2022,…
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 · E2025-02-04 · 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 interview, and policy, the facility failed to ensure the kitchen (lower kitchen) and the serving area (upstairs kitchen) was clean and sanitary when preparing food for residents. The deficient practice could increase the risk of foodborne illness. Findings include: The initial lower kitchen observation conducted on February 2, 2025 at 9:54 am revealed an open ceiling tile towards the dishwashing sink, and three other ceiling tiles with discolorations. Vents in the kitchen were covered in blackish/gray fuzzy particles. The dishwashing sink and counter area was unattended. The counter had a red sanitizer disinfectant bucket towards the top left corner, and a saturated kitchen towel towards the bottom left corner. The counter has a covering of a mix of suds and left-over food particles. The sink drain was clogged with a discolored fluid, suds, and food particles which flooded over into the sink. Small flying insects were in area and landing intermittently on the wall. Two square clear containers were also present in the sink. The initial upper kitchen…
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 · E2025-02-04 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and review of facility documentation and policy, the facility failed to ensure an effective pest control program was maintained. This deficient practice can result in the spread of disease, and not promoting a home like environment for the residents. Findings include, An initial kitchen walkthrough was conducted on February 2, 2025 at 9:54 a.m. During the walkthrough, observed multiple small flying insects in the area of the dishwashing sink. The sink area was unattended and contained standing discolored solution with food remnants clogged in the drain, which pooled into the sink. During walkthrough of the dry storage, encountered additional small flying insects in the area. Observed on February 2, 2025 at 10:06 a.m. with the dietary aid (Staff # 89), the sink with standing fluid and food and flying insects in the area. During observation of the lunch puree process on February 3, 2025 at approximately 11:00 a.m., observed alongside the dietary aide (Staff #89), the dietary manager (Staff #95) remove a deceased small brown insect from the wall, close…
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 · D2025-02-04 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and 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 clinical record review, staff interviews, and facility policy, the facility failed to ensure that a resident's representative was notified of a transfer. The deficient practice could result in resident's representative being unaware of residents discharge. Findings include: Resident #147 was admitted on [DATE] with diagnoses of metabolic encephalopathy, schizoaffective disorder bipolar type, dementia and major depressive disorder. This resident discharged on May 21, 2021. A care plan dated May 5, 2021 included resident and spouse/representative have expressed wish for discharge home to prior living with supportive services in home depending on outcome and care needs with interventions to set up home health service per resident/representative choice. However, this resident was not discharged to home. A clinical resident profile included that this resident had a Power of Attorney (POA) designated for financial and care, and that this POA was also the emergency contact. An alert charting note dated May 8,…
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 · D2025-02-04 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
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, interviews, and review of facility policies and procedures, the facility failed to ensure necessary blood pressure medications and insulin were administered according to provider instruction for one resident (#68). This deficient practice could result in side effects leading to negative resident outcomes. Findings include: -Resident # 68 was admitted to the facility on [DATE], with diagnoses that include hypertension, Type 2 Diabetes Mellitus, dysphagia (difficulty swallowing), and dependence on renal dialysis. The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had mild cognitive impairment. The resident care plan dated November 19, 2024, required that anti-hypertensive medications to be given as ordered, and to monitor for side effects such as orthostatic hypotension (low blood pressure caused by position change) and tachycardia (increased heart rate). A physician order dated November 6,…
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 before2024-12-06 · 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 documentation and policy review, the facility failed to ensure adequate supervision was provided for two residents (#3) and (#4) to prevent further resident to resident altercations. The deficient practice could result in further incidents of inadequate resident supervision. Findings include: Regarding residents #1 and #2: -Resident #1 was admitted to the facility August 27, 2024 with diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, dementia in other diseases classified elsewhere, moderate, with agitation. A care plan initiated in April 2023 and revised July 2023 revealed the resident had a focus for behavior problems related to resistance to care and wandering and impaired cognitive function/dementia or impaired thought processes related to short and long-term memory loss and dementia. Interventions included administer meds as ordered, intervening as necessary to protect the rights and safety 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.
- Potential for harm · Dcited before2024-12-06 · 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 clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided for two residents (#3) and (#4) to prevent further resident to resident altercations. The deficient practice could result in further incidents of inadequate resident supervision. Findings include: Regarding residents #1 and #2: -Resident #1 was admitted to the facility August 27, 2024 with diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, dementia in other diseases classified elsewhere, moderate, with agitation. A care plan initiated in April 2023 and revised July 2023 revealed the resident had a focus for behavior problems related to resistance to care and wandering and impaired cognitive function/dementia or impaired thought processes related to short and long-term memory loss and dementia. Interventions included administer meds as ordered, intervening as necessary to protect the rights and safety 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.
- Potential for harm · D2024-12-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when 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 clinical record review, staff interviews, and review of facility policies, the facility failed to ensure oxygen was administered as ordered by the physician for one of 3 sampled residents (#21). The deficient practice could result in residents not receiving adequate oxygen to prevent hypoxia. Findings include: Resident #21 was admitted on [DATE] and discharged [DATE] with diagnoses chronic obstructive pulmonary disease, unspecified, unspecified asthma, uncomplicated, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, unspecified symptoms and signs involving cognitive functions and awareness, legal blindness, as defined in USA). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating resident's cognitive status moderately impaired. Further review of the MDS revealed resident receiving oxygen therapy. Review of the Care Plan date-initiated March 3, 2023 revealed resident receiving oxygen therapy…
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 before2023-08-16 · 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, resident and staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#7) was free from abuse involving resident (#33). Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive disorder, recurrent; Schizophrenia and Unspecified Dementia. The Quarterly assessment dated [DATE] revealed that the resident is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 99. An Incident note dated August 14, 2023 at 6:40 PM indicated that the nurse was notified by a Certified Nursing Assistant the the resident (#7) was on the floor in another residents room (#33). When entering the room resident #7 was lying face down on the floor with visible blood pooling under her face. Upon assessing the resident she had a gash on the bridge of her nose and a wound on the left side of her head. A physician progress note dated August 15, 2023 at 2:03 PM noted that 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 before2023-08-16 · 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 clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that two residents (#7 and #33) were provided adequate supervision to prevent wandering behaviors leading to abuse. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive disorder, recurrent; Schizophrenia and Unspecified Dementia. The Quarterly assessment dated [DATE] revealed that the resident is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 99. Resident #7 was care planned for wandering behaviors and was known to wander into other resident's rooms. An Incident note dated August 14, 2023 at 6:40 PM indicated that the nurse was notified by a Certified Nursing Assistant the the resident (#7) was on the floor in another residents room (#33). When entering the room resident #7 was lying face down on the floor with visible blood pooling under her face. Upon assessing the resident…
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 before2023-05-18 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 review of policy, the facility failed to ensure a physician order for an X-ray was carried out timely for one resident (#46) and failed to ensure physician was notified regarding a change in condition for one resident (#76). The sample size was 18. The deficient practice may increase the risk for residents to sustain complications including hospitalization and/or death. Findings include: -Resident #46 admitted on [DATE] with diagnoses of primary hypertension, unspecified osteoarthritis and chronic pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. The MDS also included that the resident required extensive one-person physical assistance for most activities of daily living, had no falls since admission and/or the prior assessment and had displayed rejection of care on 1-3 days out of the 7-day look-back period. A Fall…
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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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
No federal fines in the current CMS record.
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 | 1 of 5 | 2.7 | -1.7 vs chain |
| Health inspection | 2 of 5 | 2.0 | ≈ chain avg |
| Staffing | 1 of 5 | 2.3 | -1.3 vs chain |
| Quality measures | 4 of 5 | 4.7 | -0.7 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 |
|---|---|---|---|
| ROBERTSON, BRETT | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/10/2015 |
| SAMUELIAN, ROBERT | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/10/2015 |
| SAMUELIAN, SPENCER | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/10/2015 |
| SAMUELIAN, STEPHEN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/10/2015 |
| SEASTRAND, JASON | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/10/2015 |
| WEST, CHRISTIAN | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/10/2015 |
| GLOBE-YUMA REAL ESTATE PARTNERS | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 11/01/2014 |
| HAVEN GLOBE REAL ESTATE LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 11/01/2014 |
| ESPINOSA, STEPHANIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/08/2025 |
| FRAGOSO, LINDSAY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/10/2021 |
| HEALTH GROUP MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/30/2025 |
| KUNG, SHU | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/01/2023 |
| MORA, SKIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/11/2024 |
| MUIR, MARK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/15/2015 |
CMS files one row per role, so the 36 rows in the source record cover these 14 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.
3 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.
About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $618K 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 035233. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-10, 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 →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.