Haven Of Lake Havasu
2781 Osborne Drive, Lake Havasu City, AZ 86406 · For profit - Corporation · 104 certified beds · (928) 505-5552 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0606) — most recent Apr 2026
- it has 2 actual-harm citations
- 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
- the CMS record shows $8,018 in federal fines (most recent 2024-10-17)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 held steady at 2 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 | 3.1% | 10.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.1% | 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 | 1.1% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.3% | 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 | 1.1% | 2.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.9% | 12.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.9% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.4% | 4.4% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.3% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.7% | 10.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.3% | 87.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.2% | 23.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 15.2% | 10.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.47 | 1.47 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.64 | 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.
57.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 233 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 77.5% 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 80 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 10% 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 | 57.1%CMS range 49.5–62.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 8.4–14.6 | 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 | 77.5% | 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 | 73.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 67.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 89.2% | 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 | 0.0% | 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 | 0.9% | 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 | 9.2%CMS range 5.8–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 81.3 residents a day — about 78% occupied, or roughly 23 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 3.37 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.06 hrs/resident/day on weekends vs 3.50 on weekdays — 13% thinner on weekends. RN hours go from 0.77 to 0.40 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 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.
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 12 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · Gcited before2025-02-14 · 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 documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that two residents (#9, #228) were adequately supervised in order to prevent accidental falls; and, failed to ensure items in the environment that could be utilized unsafely were stored away from one resident (#31). The deficient practice resulted in two residents being physically harmed. Findings include: -Resident #9 was admitted on [DATE]. Resident was discharged to hospital March 8, 2023 and was re-admitted on [DATE] with diagnoses that included age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with routine healing, Alzheimer's disease, unspecified dementia, unspecified severity, with other behavioral disturbance, and need for assistance with personal care. A review of the MDS (minimum data set) dated January 19, 2023 revealed a BIMS (brief interview of mental status) score of 01, indicating that the resident had severe cognitive impairment.…
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.
- Actual harm · Gcited before2024-10-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure one resident (#135) was free from self-harm following an encounter of self-reported suicidal ideation. The deficient practice could result in further neglect, harm or possible death of residents. Findings include: Resident #135 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status was conducted which revealed a BIMS score of 14, indicating resident's cognition was intact. Further review of the MDS section D for mood assessment revealed a severity score of 23. The score indicated resident was feeling down, depressed or hopeless. Additionally, trouble falling or staying asleep or sleeping too much, feeling tired or having little energy; Poor appetite, feeling bad about herself or that she is a failure or have let the family…
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 before2026-04-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff and resident interviews, review of facility documentation, and review of policy and procedures, the facility failed to protect the rights of two residents (#1 and #2) to be free from physical abuse by another resident. The sample size was 4. The deficient practice could result in the resident being in an unsafe environment. Findings Include: -Regarding Resident #1 Resident #1 was admitted on [DATE] with a diagnoses that included attention and concentration deficit, dysphagia, acute respiratory failure, muscle weakness, abnormalities of gait and mobility, and symbolic dysfunctions. A quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. A care plan initiated on February 4, 2025, had a focused area for the Resident #1 having behavioral problems related to taking others' belongings without permission and eating other people's food. It was further documented that he 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 · Dcited before2025-04-01 · 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, facility documentation, and staff interviews, the facility failed to ensure two residents (#36 and #40) were provided adequate supervision to prevent resident abuse. The deficient practice could result in residents being at risk for abuse. Findings include: -Regarding Resident #36: Resident #36 was initially admitted to the facility on [DATE] and has a reentry date of May 15, 2023 with a diagnosis that includes Coronary Artery Disease (CAD), Hemiplegia or Hemiparesis, Seizure Disorder or Epilepsy, and Schizophrenia. Review of care plan dated May 15, 2023 revealed resident have an impaired visual function related to blindness of right eye and refuses to wear glasses. The interventions initiated on May 15, 2023 included staff to place any items directly in front of resident. Review of another care plan dated May 15, 2023 revealed resident have impaired cognitive function/dementia or impaired thought processes related to impaired decision making. The interventions included 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 · D2025-02-14 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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, resident and staff interviews, and policy review, the facility failed to ensure advance directives were completed and maintained for one resident (#31). The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident's life. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care, unspecified sequelae of cerebral infarction, nontraumatic intracerebral hemorrhage in hemisphere, unspecified. A physician's order dated December 23, 2024 was written for DO NOT RESUSITATE -DNR without hold or end date; A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was 15, which indicated resident was cognitively intact. Review of the Care Plan revaled a focus for advanced directives date initiated November 17, 2022 with a goal that the residents wishes and directions will be carried out 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.
- Potential for harm · D2025-02-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY -Resident #25 was admitted to the facility on [DATE], with diagnoses that include acute and chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure. The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview Mental Status (BIMS) 15 which indicated the resident was cognitively intact. A review of the documented Self Medication Evaluation revealed, that a self-administration evaluation was conducted on January 7, 2025 at 4:00 pm. The resident #25 wanted to self-administer medications. A review of physician orders included the self-administering of medications: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 Micrograms/ACT (Fluticasone-Umeclidinium-Vilanterol) 1 inhalation, inhale orally one time a day unsupervised self-administration Rinse mouth after use Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril one time a day for allergies…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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, resident and staff interviews and observations, the facility failed to ensure proper nail care for one resident (#31) was performed. This deficient practice could result in resident grooming and hygiene needs not being met. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care, unspecified sequelae of cerebral infarction, nontraumatic intracerebral hemorrhage in hemisphere, unspecified A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was 15, which indicated cognition intact. Further review of the MDS revealed impairment on one side for the resident's upper and lower extremities, dependent with showers and bathing and required substantial/maximal assistance with personal hygiene. A review of the care plan revealed a focus for ADL self care perfomance indicating resident #31 had a deficit related to decreased mobility date initiated May 6, 2022. Interventions…
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 · D2025-02-14 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 medications were not left at the bedside for two resident. (#25, #283). The facility census was 85 and the sample was 3 residents. The deficient practice could result in harm to the residents, staff and/or visitors who have access to medications. Findings include: -Resident #25 was admitted to the facility on [DATE], with diagnoses that include acute and chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure. The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview Mental Status (BIMS) 15 which indicated the resident was cognitively intact. Resident #25's care plan did not address resident as able to self-administer medications. A medication pass observation was conducted on February 13, 2025 at 0738 am with staff member Licensed Practical Nurse (LPN) #225. Two boxes were given to look…
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 · D2025-02-14 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and review of policy, the facility failed to ensure food was stored in accordance with appropriate guidelines. The facility census was 85. The deficient practice could increase the risk for foodborne illness. Findings include: On February 11, 2025 at 12:20 PM an observation of the kitchen was conducted with the Dietary Manager (DM/Staff#280). During a review of the freezer, one box of breadsticks observed in the box with box lid and plastic packaging open, exposed to air in freezer with observable frost. Further inspection of the freezer revealed one box of bread dinner rolls in an opened plastic packaging open and exposed to freezer air. Dietary manager (DM/Staff #280) stated that dietary staff were supposed to tie the bag after opening it to ensure the packages remain closed. Staff #280 threw away the items. The walk-through of the food storage pantry revealed one 10 pound opened box of graham cracker crumbs exposed to air; one 10 pound box of bacon bits open and exposed to air; 90 oz dry storage container with no lid with bread crumbs on bottom…
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 · D2025-02-14 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and policy and procedures, the facility failed to ensure that refuse was disposed of appropriately. The deficient practice could result in an unsanitary condition and the harborage of pests and insects. Findings include: During a kitchen inspection conducted on February 13, 2025, at 8:50 a.m. with Dietary Manager (staff # 280) and Maintenance Manager (staff # 470), observation revealed the designated kitchen garbage receptacle had one of the two lids missing, leaving trash and food items exposed to the elements, animals and insects. Staff # 280 stated half of the lid had been missing for three weeks; and that, she failed to inform the maintenance department of the issue. Staff #280 stated that the garbage receptacle should have two lids and remain closed at all times. Maintenance Manager (staff # 470) stated he was unaware of the issue with the dumpster lids, but would notify the city to have it replaced. Staff # 280 and #470 stated the risks associated with not having a closed lid on the trash dumpster is, it draws pests and animals. Review…
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 before2024-12-02 · 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, interviews, review of policies, the facility failed to ensure resident # 1 did not sustain repeated fall accident and injury. This may result in residents sustaining injuries due to repeated falls. Findings include: Resident #1 was admitted on [DATE], with diagnoses of anemia, chronic pain due to trauma, depression, essential hypertension, nondisplaced fracture of base of neck of left femur, and repeated falls. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating resident #1 had moderate cognitive impairment. The baseline care plan included that the resident was at risk for falls or have had an actual fall. The goal was to be free of falls through the review date. Interventions included: anticipate and meet my needs, be sure my call light is within reach and encourage me to use it for assistance as needed, follow facility fall protocol. One intervention was added on February 10, 2023, which included: educate…
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 · D2024-08-20 · 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 review of policy and procedures, the facility failed to ensure discharge planning included developing a discharge care plan for one sampled resident (#80). The deficient practice resulted in an ineffective transition to post-discharge care, and increases the risk factors leading to preventable readmission. Findings include: Resident #8 was admitted on [DATE] with diagnoses that included rhabdomyolysis, pressure-induced deep tissue damage of the sacral region, unstageable pressure ulcer of left buttock, and unstageable pressure ulcer of right buttock. An admission Evaluation -Nursing assessment dated [DATE] revealed the resident's expectation at admission was to be discharged to the community. Review of the comprehensive care plan dated June 28, 2024, revealed an appropriate pre-discharge plan will be established by coordinating discharge plans with the Interdisciplinary Team (IDT), and helping to provide services according to care plan in an effort 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.
Show the remaining 15 citations
- Potential for harm · Dcited before2024-06-11 · 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 record review, interviews and facility documentation and policy, the facility failed to ensure one resident (#1) was free from abuse from a staff member. The deficient practice could lead to further abuse of residents. Findings include: Resident #1 was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure with hypoxia and hypercapnia, wedge compression fracture of first lumbar vertebra, history of falls, and low back pain. Review of the most recent MDS (Minimum Data Set) dated April 16, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 06, which indicated severe cognitive impairment. The facility reportable event record/ report stated that on January 6, 2024 it was reported to the administrator that registry aide (staff #5) was being unkind. The report stated after resident #1 refused shower and in attempt to give bed bath, staff #8 witnessed staff #5, with a wet cloth on her hand spun around, causing water to splash all over resident's #1 face. 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 · E2023-07-27 · tag F0606 — failed to not employ staff found guilty of abuse — patternNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on documention, staff interviews, and the facility policy and procedures, the facility failed to provide supervision as directed by the nursing board for one staff (#33). The deficient practice could result in residents being physically and/or emotionally harmed. Findings include: Review of staff #33's RN license revealed that it was issued on May 1, 2018 probationary status with the state of Arizona. The date action was taken was on July 23, 2021. Review of the, Arizona State of Board of Nursing Consent Agreement and Order Number 1805081, dated July 23, 2021 revealed that staff #33's license is hereby revoked; however; the revocation is stayed for as long as respondent remains in compliance with this order. During the stay of the revocation, respondent's nursing license is placed on probation for a minimum 36 months with terms and conditions. If respondent is non-compliant with any of the terms of the order the stay of the revocation shall be lifted and respondent's license shall be automatically revoked for a minimum period of five years. The respondent shall practice as 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.
- Potential for harm · Ecited before2023-07-27 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 review, staff interviews, and facility policy and procedures, the facility failed to ensure that medication administration for one resident (#18) met professional standards of practice, failed to ensure physicians orders for one resident (#8) were complete and failed to notify the physician of a change in condition (#65). The deficient practice could result in residents not receiving care that meets professional standards. Findings include: -Resident #18 was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus with diabetic neuropathy, chronic systolic heart failure, and morbid obesity. The care plan for Diabetes Mellitus dated August 29, 2022 included the intervention to give diabetes medication as ordered by the doctor. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. Review of the order summary revealed an order dated July 13, 2023, Humalog KwikPen Solution…
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 before2023-07-27 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
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, staff interviews, and the facility policy and procedures, the facility failed to assist one resident (#60) with repositioning. The deficient practice could result in a skin breakdown. Findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses that included generalized muscle, pathological fracture with routine healing, low back pain, and anxiety disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. It also included that the resident required a one-person extensive assist with bed mobility and used a wheelchair for ambulation. The care plan dated June 8, 2023 revealed that the resident has or is at risk for an activity daily living (ADL) self-care performance deficit. Interventions included that the resident requires one-person assistance with bed mobility. Review of the task sheet documentation for bed mobility/repositioning dated June 2023 revealed: -June 9,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-27 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide an ongoing program of activities designated to meet the needs of one resident (#18). The deficient practice could impact the psychosocial needs of the residents. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included chronic systolic heart failure, morbid obesity, anxiety, and a major depressive disorder. Note: task sheets for Bingo, family/friend visits, ice-cream socials, manicures/health and beauty, movies/TV, music, and room visits from April to June, 2023 were requested and the facility had no documentation. Review of the quarterly activities data collection dated May 4, 2023 revealed that the resident likes to watch TV/movies, and manicures. It also revealed that the resident doesn't like group activities. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-07-27 · tag F0680 — patternEnsure the activities program is directed by a qualified professional.
What the surveyor found here — an excerpt from the official record, may be distressing
Review of the employee file, staff interviews, and the policy and procedures revealed that the facility failed to ensure staff #57 had the educational requirements and experience for the position of Activity Manager. The deficient practice could result in activity assessments and the implementation of an appropriate activity program not being met for residents. Findings include: Staff #57 was hired on May 23, 2023 as the Activity Manager. Review of staff #57's resume revealed that staff #57's level of education was a high school diploma. There was no documentation of work experience or certification in recreational activities. Review of the job description revealed that the Activity Manager reports to the Executive Director, and directs the development, implementation, supervision, and ongoing evaluation of the activities program. Tasks and responsibilities include to actively monitor the residents' responses and evaluate these responses to the programs in order to determine if the activities meet the assessed needs of the resident. It also included the scheduling and supervision 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 · E2023-07-27 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such 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 clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#46) was provided pain management services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for residents. The census was 58, the sample was 16 residents. Findings include: Resident #46 was admitted on [DATE] with diagnoses that included hemiparesis and hemiplegia, fracture of left femur, protein calorie malnutrition, COPD, major depressive disorder, chronic pain ddue to trauma, and need for assistance with personal care. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment included that the resident had constant pain in the last 5 days and received scheduled pain medication and as needed (PRN). An active care plan revealed the following areas of focus: - Risk for pain related to acute and chronic pain 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.
- Potential for harm · D2023-07-27 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 policy review, the facility failed to revise the comprehensive care plan to include assessed goals and needs for one resident (#8). The deficient practice has the potential to cause resident's specific nutritional care needs not being met. Findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses that included moderate protein-calorie malnutrition, paraplegia, complete, and need for assistance with personal care. The care plan initiated on August 27, 2020 and revised on November 10, 2021 revealed the resident had a nutritional problem related to paraplegia, required assistance/was total dependent for eating. Further review of the care plan revealed the resident required build-up utensils to eat and total assistance to eat. The quarterly Minimum Data Set, dated [DATE] included a brief interview for mental status score of 15, indicating the resident was cognitively intact. Further review revealed the resident required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-27 · 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 clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure the necessary treatment and services were provided for one resident (#65) as ordered by the physician regarding daily weights, and notficiation of changes in condition. The facility census was 58, and the sample was 16 residents. The deficient practice could result in the physician not being aware of changes in condition. Findings include: Resident #65 was admitted on [DATE] with diagnoses that included urinary tract infection, pseudomonas, hypertensive heart and chronic kidney disease with heart failure, and type 2 diabetes mellitus. Revuew if the clinical record revealed no evidence that the physician was notified of a residents change in condition that included weight change, edema and shortness of breath prior to the resident's death in the facility. Review of a Nursing admission Evaluation dated May 18, 2023, revealed that the resident expected to be discharged to the community, 3+…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-27 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure a registered nurse was scheduled for 8 consecutive hours on September 18, 2022. The deficient practice could impact the quality of care provided to residents. Findings include: Review of the daily staff posting dated September 18, 2022 revealed that a registered nurse (RN) was not scheduled to work on the day shift, 6 a.m. to 6 p.m. or on the night shift, 6 p.m. to 6 a.m. Review of the daily assignment sheet dated September 18, 2022 revealed that there were three licensed practical nurses (LPNs) scheduled for the day shift, 6 a.m. to 6 p.m. and three LPNs scheduled to work the night shift, 6 p.m. to 6 a.m. Review of the time cards dated September 18, 2022 revealed that three LPNs worked the day shift, 6 a.m. to 6 p.m. and three LPNs worked the night shift, 6 p.m. to 6 a.m. During an interview conducted on July 26, 2023 at 9:01 a.m. with Director of Nursing (DON/staff #30), Human Resources (HR/staff #12), and the resource registered nurse (RN/staff #105), the daily staff…
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 · E2022-06-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — patternProvide 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 review, staff interviews, review of policies and procedures, the facility failed to ensure one resident (#20) consistently received care and services to assess, treat, and identify pressure ulcers. The sample size was 2. The deficient practice could result in delayed identification of pressure ulcers and worsening of pressure ulcers. Findings include: Resident #20 admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included stage 3 pressure ulcer of the sacral region, type 2 diabetes mellitus, muscle weakness, and need for assistance with personal care. Review of a Braden Scale for predicting pressure sore risk dated February 7, 2022/signed February 8, 2022 had a score of 15 which was low risk. Review of the physician's orders revealed an order dated February 7, 2022 to complete a skin check weekly. However, no weekly skin check and wound assessments were documented until April 12, 2022. Review of the physician's orders revealed an order dated February 10,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 observations, staff interviews, and policy review, the facility failed to ensure the resident environment remained free of accident hazards for three residents (#15, #24, and #17), by failing to ensure safe water temperatures were maintained. The deficient practice could result in residents sustaining burns related to hot water temperatures. Findings include: -Resident #15 was readmitted to the facility on [DATE] with diagnoses that included diabetes mellitus and coronary artery disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 12 on Brief Interview for Mental Status (BIMS) which indicated the resident had moderate cognitive impairment. The assessment also revealed the resident required extensive assistance of two+ persons for transfers and bed mobility. The water temperature was checked in resident #15 room on 6/6/22 at 3:24 PM. The hot water temperature was observed to be 123 degrees Fahrenheit (F). -Resident #24 was admitted to the facility on [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, policy review, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of two residents (#8 and #20). The sample size was 18 residents. The deficient practice could result in assessments not being accurate and in data that is not accurate for quality monitoring. Findings include: -Resident #20 admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included a stage three pressure ulcer of the sacral region, COVID-19, and pneumonia. Review of the Pressure Ulcer Documentation and Assessment form dated February 7, 2022 revealed the resident had a left buttock stage 2 pressure ulcer that was present on admission. Review of the Pressure Ulcer Documentation and Assessment form dated February 17, 2022 revealed the resident had a left heel stage three pressure ulcer. Review of the admission MDS assessment dated [DATE] revealed the resident had an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 policy and procedure, the facility failed to ensure that professional standards were followed for one resident (#20) by not following the physician order regarding blood sugars. The sample size was 5. The deficient practice could result in an adverse outcome to residents. Findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of the sacral region stage III, COVID 19, and Type 2 Diabetes Mellitus without complications. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a score of 12 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. A care plan initiated on April 10, 2022 revealed the resident has diabetes mellitus. The goal was that the resident would have no complications related to diabetes. The intervention stated the resident will receive diabetes medication as ordered by the physician. Review of the physician's orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-09 · tag F0685 — isolatedAssist 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 resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that one sampled resident (#18) was assisted with making a vision appointment. The deficient practice could result in decreased vision abilities. Findings include: Resident #18 was admitted on [DATE] with diagnoses that included fracture of unspecified carpal bone, neutropenia and glaucoma. During the initial part of the survey, an interview was conducted with resident #18 on June 6, 2022 at 11:58 AM. Resident #18 stated that her vision is poor and she has asked to see the eye doctor for months and the facility has not made an appointment with an eye doctor. The resident stated that she had glasses but she does not see as well with the glasses anymore. The resident stated that she is also concerned about glaucoma and lost vision in her left eye since February. The resident stated that she is still waiting to see the eye doctor about the vision loss. The resident stated she is anxious about losing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,018 in federal fines across 1 penalty.
- $8,018 — penalty dated 2024-10-17
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to HAVEN HEALTH — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.7 | -0.7 vs chain |
| Health inspection | 1 of 5 | 2.0 | -1.0 vs chain |
| Staffing | 2 of 5 | 2.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 19 homes this chain runs (chain average 2.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ROBERTSON, BRETT | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/22/2025 |
| SAMUELIAN, ROBERT | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/22/2025 |
| SAMUELIAN, SPENCER | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/22/2025 |
| SAMUELIAN, STEPHEN | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/22/2025 |
| SEASTRAND, JASON | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2017 |
| WEST, CHRISTIAN | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/22/2025 |
| HAVEN HEALTH PROPERTIES LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 06/01/2017 |
| HAVEN LAKE HAVASU REAL ESTATE LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 06/01/2017 |
| HEALTH GROUP MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/25/2024 |
| ESPINOSA, STEPHANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/14/2024 |
| FRAGOSO, LINDSAY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/10/2021 |
| LONGHURST, STOCK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/15/2020 |
| ONG-VELOSO, ANGELO | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| PONITHIEUX, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/10/2023 |
| YENTES, CAMERON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/26/2024 |
CMS files one row per role, so the 36 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.
This home reported $576K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 035240. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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.