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Haven Health Green Valley, LLC

150 North La Canada Drive, Green Valley, AZ 85614 · For profit - Limited Liability company · 111 certified beds · (520) 625-0178 Medicare & Medicaid certified

Call the home — (520) 625-0178 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2024Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (18% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
175 S La Canada Dr Ste 141 · (520) 625-8562 · Call to confirm hours
Pharmacy
313 W Esperanza Blvd · (520) 648-2417 · Call to confirm hours
Grocery
Safeway1.1 mi
465 E Mariposa · (520) 648-7947 · Call to confirm hours
Park
Park Centre Green Valley Arizona · Typically dawn to dusk
Place of worship
300 W Esperanza Blvd · (520) 625-4712

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 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.9%10.7%15.4%better
Long-stay residents who lose too much weight0.0%5.3%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection1.9%1.2%2.0%typical
Long-stay residents with depressive symptoms5.3%3.9%6.5%better
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.7%2.1%3.3%worse
Long-stay residents whose ability to walk worsened12.3%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.5%21.0%18.9%typical
Long-stay residents given the seasonal flu vaccine98.3%94.6%95.3%typical
Long-stay residents with pressure ulcers0.8%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control25.9%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table1.8%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine89.7%87.3%79.4%better
Short-stay residents rehospitalized after admission18.2%23.7%22.6%better
Short-stay residents with an outpatient ER visit4.9%10.4%12.0%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.

68.7% 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 349 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.7%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
59.1%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 59.1% 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 137 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF68.7%CMS range 64.9–73.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 8.4–13.410.7%Oct 2022–Sep 2024no 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 discharge59.1%56.6%Oct 2024–Sep 2025CMS 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 discharge61.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge63.5%50.0%Oct 2024–Sep 2025CMS 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 identified98.2%98.7%Oct 2024–Sep 2025CMS 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 setting91.7%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 4.6–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 2022–Sep 2024CMS 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

0.38
RN hours/ resident / day
0.77
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.22
Total nurse hours/ resident / day
0.32
RN hoursweekends
18.4%
Total nursing turnover
14.3%
RN turnover

How full it usually is: this home is certified for 111 beds and averages 102.3 residents a day — about 92% occupied, or roughly 9 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 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 2.86 hrs/resident/day on weekends vs 3.37 on weekdays — 15% thinner on weekends. RN hours go from 0.40 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 18% is below 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

2
deficiencies at the latest standard inspection (2026-06-05)
9
at the previous standard inspection (2024-05-23)

Deficiencies are fewer than at the previous inspection — improving. 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.

ABCDEFGHIJKL

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · D2026-06-05 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 the facility's policy and procedures, the facility failed to ensure a significant change in condition assessment was completed for Resident #120. The universe was 19. The deficient practice could result in residents not receiving the necessary care and services to maintain the highest and practicable wellbeing.Findings include:Resident #120 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, dementia, and adjustment disorder.An admission Minimum Data Set (MDS), dated [DATE] revealed Resident #120 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated she had moderate cognitive impairment. The same MDS also indicated she was not receiving hospice services.An entry in the clinical record titled, Psych Follow Up, dated [DATE] at 7:00 A.M. noted that Resident #120 was experiencing an increase in behavioral changes such as increased aggression, anger, and yelling with staff. It also noted that…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    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 the clinical record review, observations, interviews, facility documentation, and policy, the facility failed to ensure that infection control practices for Enhanced Barrier Precautions (EBP) were followed for one resident (Resident #11). This deficient practice can result in contamination and the spread of infection. The universe is 15, and the sample is one resident. Findings include: Resident #11 was admitted to the facility on [DATE], with conditions that included type 2 diabetes mellitus, Hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, pressure ulcer of the sacral region, stage 4, urinary tract infection, and a Foley catheter.The quarterly Minimum Data Set (MDS) accepted on May 15, 2026, revealed that the resident had a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. An observation was conducted on June 02, 2026, at 1:06 p.m. and at 2:27 p.m. Resident #11 did not have a numerical 6 on the door frame, which indicates Enhanced…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 the facility policy and procedures, the facility failed to ensure that floor tiles, laminate flooring, shower drain, and door frame in common areas were safe for residents ambulating and showering. The deficient practice could result in residents falling and/or being injured. Findings include: On May 21, 2024 at 4:23 p.m., a walk through of the facility was conducted and the following environmental issues were observed: -one rectangular panel of the laminate flooring in Hall 100, between rooms #127 and #128, was broken and approximately half an inch was missing from one of the corners of the laminate. -the laminate panel in the doorway of room [ROOM NUMBER] was observed to have approximately 16.5 inches in length broken and missing. -six tiles in Hall 100 were cracked and/or broken. -the transition strip between the laminate flooring and the tile flooring on Hall 100 by room [ROOM NUMBER] was cracked in multiple areas. -in the hallway, near room [ROOM NUMBER] a piece…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-23 · tag F0680 — pattern
    Ensure 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 file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents. Findings Include: A review of the personnel file for the role of activity manager (staff #432) was conducted on May 21, 2024. However, review of file did not reveal evidence that staff #432 possessed the qualifications required for the role of activities director. An interview was conducted on May 21, 2024 at 1:12 P.M. with staff #498, human resource manager. Staff #498 stated that the role of activity manager had no additional qualifications needed beyond the scope of qualifications that staff #432 had. She stated that the facility did not require licensure or registration for the activity manager. An interview was conducted on May 21, 2024 at 2:14 P.M. with staff #605 , administrator. Staff #605 stated that he was aware that the current activities director was not licensed or…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-23 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that code status was accurate and consistent in the medical record for one resident, #242. The deficient practice could result in resident not receiving care consistent with their signed advance directive. Findings include: Resident #242 was admitted on [DATE] with diagnosis including hypotension, hypertension, presence of a cardiac pacemaker, major depressive disorder-recurrent, obstructive and reflux uropathy, diverticulitis of large intestine and edema. A review of the MDS (minimum data set) revealed that the admission MDS was still noted to be in progress. A review of the physician orders dated May 15, 2024, revealed that the resident was a full-code, meaning that cardiopulmonary resuscitation and other resuscitation procedures should be used to keep the resident alive. A review of the care plan, dated May 16, 2024, revealed that the resident's advanced directives were in…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-23 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 ensure that one resident (#47) had the right to privacy. The deficient practice could result in residents being denied their rights and impact psychosocial well-being. Findings include: Resident #47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavioral disturbance, adjustment disorder, and major depressive disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 6 indicating the resident had a severe cognitive impairment. Review of the care plan dated February 14, 2023 revealed a behavior care plan related to impaired cognition as evidenced by verbal aggression toward staff, rejecting needed care, yelling at staff, and obsessing over particular items. A progress note dated October 11, 2023 revealed that the resident gets easily irritated with other residents and staff, yells out and is often impulsive. A…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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, policies and procedures, the facility failed to protect the rights of two residents (#50, and #3) to be free from abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken. Findings include: Regarding incident involving residents #50 and 191: -Resident #50 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, auditory hallucinations, visual hallucinations, anxiety disorder, and disorientation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's cognitive skills for daily decision making is severely impaired. The MDS also indicated that the resident was negative for indicators of psychosis, behavioral symptoms, and wandering during the assessment period. However, the MDS noted that the resident exhibited rejection of care which occurred 1-3 days during the assessment…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-23 · tag F0645 — isolated
    PASARR 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 documentation, staff interviews, and the facility policy and procedure, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level I for one resident (#24), and failed to submit the PASRR Level II to the state agency. The deficient practice could result in residents not receiving additional services that are needed. Findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included schizophrenia unspecified, bipolar disorder, and Parkinsonism. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 11 indicating the resident had a moderate cognitive impairment. Review of the PASRR Level I dated June 6, 2023 did not reveal any serious mental illnesses, anti-psychotic medication, or assessment for substantial functional limitations. Due to the form not being completed, it was not submitted to the state agency for a PASRR Level II. Review of the care plan dated June 12, 2023 revealed that 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-23 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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, interviews and policy review, the facility failed to ensure that physician's orders was followed regarding one resident's (#31) AV (arteriovenous) fistula. The deficient practice could result in the resident's AV fistula failing. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, hypertensive chronic kidney disease, Parkinsonism, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, and dependence on renal dialysis. Review of the order summary report revealed a physician order dated June 5, 2018 which indicated No Blood pressure or venipuncture to AV fistula site every shift for left arm. A care plan initiated on June 28, 2018 and revised on March 2, 2023 indicated that resident needs dialysis related to end stage renal failure. The goal was that the resident would not have signs and symptoms of complications from dialysis. Interventions included: Do not draw…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that two residents (#75 , #241) were assessed, monitored and had orders for self-administration of medications and that one resident (#23) was monitored with appropriate level of supervision. The deficient practice could result in residents being injured. Findings include Resident #23 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, hypertensive chronic kidney disease, anxiety disorder, and a major depressive disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the the care plan dated September 12, 2023 revealed a behavior care plan related to dementia as evidenced by impaired safety awareness, physical behaviors, resistive to care, verbal behaviors, and wandering/exit seeking. Interventions included to administer medications as ordered,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Dcited before2024-05-23 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each 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, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#41). The deficient practice could result in residents not receiving care and services for oral/dental conditions. Findings include: Resident # 41 was initially admitted to the facility on [DATE] with diagnoses that included hemiplegia, hemiparesis, dysphagia, atherosclerotic heart disease, hypertensive heart disease, chronic diastolic heart failure, and chronic obstructive pulmonary disease. A dental note dated September 8, 2022 revealed that a consultation visit was completed. The findings/recommendations was ext (extraction) of #26 (lateral incisor), 27 (cuspid), and 28 (first bicuspid). The next schedule appointment was marked as October 5, 2022. However, further review of dental referral notes did not reveal any documentation of that visit or if that visit occurred. A care plan initiated on February 28, 2023 revealed that 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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, staff interviews, and policy review, the facility failed to ensure that one resident (#17) was free from sexual abuse from another resident (resident #51). The deficient practice could result in further incidents of resident to resident abuse. Findings Include: -Resident #17 (Alleged victim) was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia, depression, anxiety, chronic kidney disease, and type 2 diabetes. A behavioral care plan with a start date of August 29, 2023 revealed resident #17 has impaired cognitive function, impaired decision-making related to Alzheimer's dementia with noted interventions of resident needing approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, instructions, and to keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of a quarterly…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-13 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on personnel file review, staff interviews, and facility policy, the facility failed to ensure that two of two sampled Certified Nursing Assistants (CNA/staff #100 and #91) were able to demonstrate competencies and skills necessary to provide care for residents. The census was 80. The deficient practice could result in inadequate care for residents. Findings include: Review of a personnel file for a CNA (staff #100) revealed a hire date of 05/14/03, for hourly employment. The personnel record contained no evidence of a comprehensive evaluation for nursing skills and competencies for 2022. Review of a personnel file for CNA/staff #91 revealed a hire date of 08/12/20, for hourly employment. The personnel record contained no evidence of a comprehensive evaluation for nursing skills and competencies for 2022. On 01/11/23 at 12:52 p.m. an interview was conducted with the Staffing Coordinator (staff #1). She stated that staff are evaluated for skills upon hire. She stated that she was not sure how often CNAs are re-evaluated. She stated that Human Resources sends reports 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-13 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide 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

    Based on observations, staff interviews, and policy review, the facility failed to ensure their system of medication records is complete to enable accurate reconciliation and accounting for all controlled medications. The deficient practice could result in misappropriation of residents' medications. Findings Include: -Prior to medication pass observation conducted on January 11, 2023 at 8:26 a.m. with a licensed nurse (LPN/ staff #47), she was observed handed medication cards wrapped in the reconciliation sheets to the assistant director of nursing (ADON/staff #109). Staff #109 walked away with medication cards in her hands to another unit. Following this observation, an interview was conducted with staff #47 on January 11, 2023 at 8:50 a.m. Staff #47 stated the medications that was given to staff #109 are narcotic medications of the residents that have been discharged or have their orders discontinued. Staff #47 stated that staff # 109 or the director of nursing (DON/ staff #41) picks up the discontinued controlled medications once a week or whenever they have a chance. Staff #47…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-13 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 clinical record , staff interviews and review of the facility policy, the facility failed to ensure the pharmacist identified adequate monitoring for the use of medications in the pharmacy review for 5 residents (#32,#14,#37, #41 and #25). The deficient practice could allow for medication side effects and adverse consequences to go unadressed. Findings include: Regarding Resident #14- Resident #14 was admitted [DATE] with diagnoses to include the primary diagnosis of Covid 19 and other diagnoses of schizoaffective disorder bipolar type, bipolar II disorder, generalized anxiety disorder, major depressive disorder and dementia with other behavior disturbance. In the care plan initiated March 14, 2019, a focus area revealed that the resident had a behavior problem and interventions included to administer medications as ordered and to monitor for effectiveness and side effects. The care plan further revealed that the resident received antidepressant medication and psychotropic medication and…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-13 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 five out of five residents (#32, #41, #14, #37, and #25) receiving psychotropic medications received consistent monitoring for behaviors and side effects. The facility census was 80. The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: -Resident #32 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and post traumatic seizures. An Abnormal Involuntary Movement Scale (AIMS) dated 11/17/22 revealed a score of Not Applicable (NA). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. The resident reported no feelings of depression, and he displayed no symptoms of psychosis or behaviors. A physician ' s order dated 11/30/22 revealed…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-01-13 · tag F0790 — failed to provide dental care — pattern
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review, resident and staff interviews, and policy, the facility failed to ensure that one resident (#54) was assisted in obtaining routine dental care. The sample size was 20. The deficient practice could result in residents ' dental needs not being met. Findings include: Resident #54 admitted to the facility 07/06/21 with diagnoses that included Alzheimer ' s disease with late onset, dementia in other diseases classified elsewhere, without behavioral, psychotic, or mood disturbance and major depressive disorder, recurrent, in remission. Review of the admission Nursing Review dated 07/06/21 revealed the resident had no missing, broken, obvious or likely cavity or broken natural teeth. An activities of daily living self-care performance deficit care plan dated 08/03/21 related to dementia with behaviors had a goal to maintain current level of function. Interventions included supervision/limited assistance with personal hygiene and oral care. A physician ' s order dated 12/09/21 included acetaminophen (analgesic) 500 milligrams (mg). Give 500 mg every 6 hours…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-13 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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, the facility failed to ensure one resident (#32) and/or their representative was informed of the risks and benefits of psychotropic medications prior to administration. The sample size was 20. The deficient practice could result in residents and/or their representatives not being fully informed of the risks, benefits and alternatives to proposed treatment. Findings include: -Resident #32 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and post traumatic seizures. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. The resident reported no feelings of depression, and he displayed no symptoms of psychosis or behaviors. A physician ' s order dated 11/30/22 revealed quetiapine fumarate (antipsychotic) 25 mg (milligrams): give…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-13 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 and procedure, the facility failed to ensure an advanced directive was accurate for one resident (#54). The sample size was 20. The deficient practice could result in residents ' wishes not being honored. Findings include: Resident #54 admitted to the facility [DATE] with diagnoses that included Alzheimer ' s disease with late onset, dementia in other diseases classified elsewhere, without behavioral, psychotic, or mood disturbance and major depressive disorder, recurrent, in remission. An admission progress note dated [DATE] at 3:27 p.m. included that the resident had been admitted via medical transport. An Advanced Directive Statement dated [DATE] revealed the resident ' s directive included cardiopulmonary resuscitation measures (CPR), artificial hydration, hospitalization, antibiotic therapy, and pain medication. The resident signed the directive herself on [DATE]. A facility representative witnessed the directive on the same date. A Prehospital…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-13 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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, policy review and CMS regulations, the facility failed to ensure that one resident (#56) received a timely Advanced Beneficiary Notification, within 48-hours, for termination of part A Medicare services. Findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Major Depressive Disorder-recurrent / moderate, and Primary insomnia. Review of the MDS (Minimum Data Set) for resident #56, dated December 4, 2022, revealed a BIMS (Brief Interview of Mental Status) score of 01, indicating severe cognitive impairment. Record review of the nursing progress notes revealed that resident #56 remained in the facility on private pay after termination of Medicare Part A services. On January 10, 2023 at 2:01 pm a form, SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review, was provided by the facility. The form included Part A services last covered day was on December 7, 2022. Per the document, the notice…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-13 · tag F0644 — isolated
    Coordinate 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 an updated pre-admission screening and resident review (PASRR) was completed for one resident (#14). The deficient practice could lead to residents not receiving needed care and services. Findings include: Resident #14 was admitted [DATE] with diagnoses to include the primary diagnosis of Covid 19 and secondary diagnoses of schizoaffective disorder bipolar type, bipolar II disorder, generalized anxiety disorder, major depressive disorder and dementia with other behavior disturbance. The diagnosis of dementia is listed as having an onset of October 1, 2022. All the diagnoses were present upon admission. Review of the clinical record revealed a completed level 1 PASRR dated October 10, 2012. The level 1 PASRR revealed that the resident had serious mental illness and a level 2 PASRR should be completed. A letter dated October 19, 2012 from the PASRR coordinator revealed that 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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, the facility failed to ensure two residents (#51 and #56) care plans were updated/revised to meet their changing needs. The sample size was 20. The deficient practice could result in inadequate care and/or not meeting the needs of the resident. Findings include: -Resident #51 admitted to the facility 12/20/21 with diagnoses including paroxysmal atrial fibrillation, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease and rheumatoid arthritis. The admission Nursing Review dated 12/20/21 at 4:16 p.m. revealed the resident had no pressure sores, and that his skin was intact. Review of the Baseline Care Plan dated 12/20/21 at 4:44 p.m. included potential for skin breakdown/pressure ulcers due to decreased mobility and incontinence. No goal or interventions were identified in the plan of care. A potential risk for pressure ulcer development care plan initiated on 01/09/22 related to immobility had a goal for 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-13 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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, the facility failed to ensure one resident (#183) did not receive oxygen without a physician ' s order. The sample size was 20. The deficient practice may increase the risk for residents to receive unnecessary medications. Findings include: Resident #183 was readmitted to the facility on [DATE] with pleural effusion, not elsewhere classified, acute and chronic respiratory failure with hypoxia and acute on chronic diastolic (congestive) heart failure. A baseline care plan dated 03/09/22 included oxygen related to difficulty breathing with increased activity related to effects of congestive heart failure, chronic obstructive pulmonary disease, pneumonia, etc. The goals included to maintain a normal breathing pattern as evidenced by non-labored respirations, normal skin color, and regular respiratory rate/pattern and to maintain a pulse oximetry level at or above 90%. Physician's orders dated 03/09/22 included albuterol sulfate hydro…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-13 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    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 interview, and review of facility policy, the facility failed to ensure that a discharge summary for one resident (#3) contained a recapitulation of the resident's stay and all pre and post discharge medications. Findings include: -Resident #3 was admitted on [DATE] with diagnosis that included COVID-19, traumatic subarachnoid hemorrhage, periprosthetic fracture around internal prosthetic right knee joint, hypertensive chronic disease with stage 1 through stage 4, and type 2 diabetes mellitus. Review of the physician order summary revealed an order for occupational therapy and physical therapy 5 times a week for eight weeks starting September 29, 2022 for therapeutic exercises and gait training. A 5-day MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 11, indicating moderately impaired cognition. The assessment included that the resident required extensive physical assistance from two staff members for transfer, bed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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, and review of policy, revealed the facility failed to ensure one resident (#56) received treatment and services in accordance with professional standards of practice. The deficient practice could result in resident not receiving the treatment based on their assessed need. Findings include: -Resident #56 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavior disturbances, major depressive disorder, and primary insomnia. Review of admission nursing assessment dated [DATE] at 2:11 p.m., stated no open lesion on skin. However, in another section of the assessment included a note which stated the resident have a small scab on the chin. Further review of the assessment did not include measurement or assessment of the scab. A physician progress note dated September 15, 2022 at 9:00 a.m., stated the resident has a facial lesion on the chin that does not heal, acute, that it could be cancer or just a lesion. The note…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-13 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    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, clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#54) was provided assistance with obtaining audiology services. The sample size was 20. The deficient practice may contribute to the resident ' s confusion and agitation. Findings include: Resident #54 admitted to the facility on [DATE] with diagnoses including Alzheimer ' s disease, dementia in other diseases classified elsewhere and major depressive disorder. An admission Nursing Review dated 07/06/21 revealed the resident had impaired hearing. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 5 on the Brief Interview for Mental Status (BIMS) assessment, indicating severe cognitive impairment. The resident was assessed to have minimal difficulty hearing and that she displayed no behavioral symptoms towards herself or others. A communication problem care plan initiated 08/03/21 related to a hearing deficit had a goal for the resident to maintain her…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 clinical record reviews, observations, staff interviews, facility documentation, and policy and procedures, the facility failed to ensure that one resident (#51) received care and services, consistent with professional standards of practice, to prevent, treat, and/or heal a pressure ulcer. The sample size was 20. The deficient practice could result in development, worsening, and/or infection of pressure ulcers. Findings include: Resident #51 admitted to the facility 12/20/21 with diagnoses including paroxysmal atrial fibrillation, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease and rheumatoid arthritis. The admission Nursing Review dated 12/20/21 at 4:16 p.m. revealed the resident had no pressure sores, and that his skin was intact. Review of the Baseline Care Plan dated 12/20/21 at 4:44 p.m. included potential for skin breakdown/pressure ulcers due to decreased mobility and incontinence. However, no goal or interventions were identified in the plan of care. A…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

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 →

RatingThis homeChain avg
Overall 5 of 52.7+2.3 vs chain
Health inspection 4 of 52.0+2.0 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 5 of 54.7+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 / managerTypeRoleSince
ROBERTSON, BRETTIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
SAMUELIAN, ROBERTIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
SAMUELIAN, SPENCERIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
SAMUELIAN, STEPHENIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
SEASTRAND, JASONIndividualDIRECT OWNERSHIP INTEREST; CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
WEST, CHRISTIANIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
HAVEN GREEN VALLEY REAL ESTATE LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/21/2025
HAVEN HEALTH PROPERTIES LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/21/2025
MUIR, MARKIndividualCONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
SHAH, VIRAGIndividualCONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/14/2025
EAGLEN, ROBYNIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
HATCH, BRANDONIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
ESPINOSA, STEPHANIEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
FRAGOSO, LINDSAYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/03/2025
HEALTH GROUP MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/21/2025

CMS files one row per role, so the 43 rows in the source record cover these 15 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.

$11.0M
Net patient revenuemost recent cost report
+10.2%
Operating marginrevenue minus expenses
$691K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 57%Medicare 15%Other / private 28%

This home reported $691K 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

$341per resident / day
operating cost
$10,364per month
≈ monthly operating cost
$380per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Arizona
$8,365/mo
Nursing home (semi-private)
$11,437/mo
Nursing home (private)
$6,250/mo
Assisted living

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 035073. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-05, 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.

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