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Desert Haven Care Center

2645 East Thomas Road, Phoenix, AZ 85016 · For profit - Limited Liability company · 115 certified beds · (602) 956-8000 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citations — no harm found (F0740, F0758)3 actual-harm citations$75,868 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 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 $75,868 in federal fines (most recent 2026-04-15)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
2530 E Thomas Rd · (602) 395-3354 · Call to confirm hours
Pharmacy
Oportun0.3 mi
3130 E Thomas Rd · (623) 565-9110 · Call to confirm hours
Grocery
3036 E Thomas Rd · (602) 468-9188 · Call to confirm hours
Park
2700 N 32nd St · (602) 256-3220 · Typically dawn to dusk
Place of worship
2828 E Thomas Rd · (602) 604-1874

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 3 of 5
Long-stay residentspeople who live here 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 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 rating1★
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 increased20.3%10.7%15.4%worse
Long-stay residents who lose too much weight1.3%5.3%5.4%better
Long-stay residents with a catheter left in their bladder1.5%0.8%0.9%worse
Long-stay residents with a urinary tract infection0.3%1.2%2.0%better
Long-stay residents with depressive symptoms0.0%3.9%6.5%check this — see note marked star below the table
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 injury1.9%2.1%3.3%better
Long-stay residents whose ability to walk worsened10.6%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication32.0%21.0%18.9%worse
Long-stay residents given the seasonal flu vaccine97.6%94.6%95.3%typical
Long-stay residents with pressure ulcers6.2%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control20.7%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table37.2%10.6%17.1%worse
Short-stay residents given the seasonal flu vaccine60.0%87.3%79.4%worse

* 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.

0.03U.S. median 0.31
Therapy hours / resident / day
0.01hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.03 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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 data for this measure is missing or was not submitted. 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 staynot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

2
deficiencies at the latest standard inspection (2025-09-05)
5
at the previous standard inspection (2024-04-17)

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 13 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Gcited before2026-03-02 · 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, and review of facility policies and procedures, the facility failed to protect the rights of one (#5) of three sampled residents to be free from abuse by another resident (#19). This failure resulted in Resident #5 sustaining facial trauma, including bilateral nasal bone fractures and a laceration to the left ear after being repeatedly struck by Resident #19. The deficient practice could result in further abuse of residents.Findings include:-Resident #5 (alleged victim) was admitted to the facility on [DATE], with diagnoses including dementia with other behavioral disturbance, dementia in other diseases classified elsewhere with agitation, essential (primary) hypertension, major depressive disorder, recurrent severe without psychotic features, unsteadiness on feet, history of falling, weakness, brief psychotic disorder, and hearing loss.The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #5 had a Brief…

    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
  • Actual harm · G2025-12-17 · 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, interviews and review of facility policy and procedure, the facility failed to ensure physician orders were followed regarding blood glucose monitoring; and, failed to ensure a healthcare provider was notified of abnormal blood glucose reading for one of 3 sampled resident (#44). The deficient practice led to the resident being admitted to the intensive care unit of a hospital with hyperglycemia and treatment for diabetic ketoacidosis.Findings Include: Resident #44 was admitted on [DATE], and re-admitted on [DATE], with diagnoses of type 1 diabetes mellitus, cerebral infarction, long term use of insulin, unspecified dementia, unspecified psychosis, and other sequelae of cerebral infarction.A care plan dated June 7, 2024, revealed Resident #44 had diabetes mellitus. Interventions included: diabetic medication and fasting serum blood sugar as ordered by physician; to educate resident regarding medications and importance of compliance and have resident verbally state 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-08-23 · 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 clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided to one resident (#1) to prevent elopement. The deficient practice could result in injury or harm to the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, aphasia following cerebral infarction, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, anoxic brain damage, vascular dementia, mild, with agitation, dysphagia, epilepsy, intractable without status epilepticus. The minimum data set (MDS) assessment was currently in progress for new admission to facility and had not been completed. The elopement risk assessment dated [DATE] revealed a score of 14 indicating the resident was a high risk to wander. Review of the care plan dated August 21, 2024 revealed the resident has a history of eloping. Interventions included 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-09 · 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 review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#87, and #37) to be free from physical abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken. Findings include: -Resident #87 (alleged victim, AV) was admitted to the facility on [DATE] with diagnoses that included Schizophrenia, social pragmatic communication disorder, anxiety disorder, autistic disorder, difficulty walking, cognitive communication deficit, generalized muscle weakness and other comorbid conditions. A behavioral care plan revised April 21, 2026 indicated that the resident #87 has a behavioral problem as evidenced by being intrusive to others, and verbally aggressive toward others. Interventions include discussing the behaviors with the resident and explaining and/or reinforce why behavior is unacceptable. Also included in the interventions is to approach calmly, divert…

    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 · Dcited before2026-05-01 · 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, and review of facility policies and procedures, the facility failed to protect the rights of one (#16) of three sampled residents to be free from physical abuse by another resident (#22). The deficient practice could result in further abuse of residents.Findings include:-Regarding Resident #16:Resident #16 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with other behavioral disturbance, anxiety disorder, delusional disorder, reduced mobility, weakness, homicidal ideations, personal history of traumatic brain injury, drug-induced subacute dyskinesia, and depression.The care plan for Resident #16 revealed a focus initiated on June 26, 2025, for a behavior problem related to physical aggression, hallucinations, and intrusive behaviors. Interventions included to protect the rights and safety of others, diverting attention, and removal of Resident #16 from situations and taking him to another location as…

    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 · Dcited before2026-01-26 · 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, and policy review, the facility failed to ensure that one resident (#78) was free from abuse by another resident (#89). The deficient practice could result in residents being physically and emotionally harmed.Findings Include:-Regarding Resident #89:Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus.A care plan focus initiated on May 29, 2024, revealed the resident having a behavior problem related to psychosis as evidenced by delusions, refusing care, being verbally aggressive/abusive, demanding, intrusive, wandering at times, and inappropriate sexual advances to females, with an intervention to intervene as necessary to protect the rights and safety of others.A care plan focus initiated on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-26 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that the abuse policy was implemented following an incident involving resident-to-resident abuse between two residents (#89 and #78). The deficient practice could result in continued abuse of residents and physical or emotional harm to residents. Findings Include:-Regarding Resident #89:Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus.A care plan focus initiated on May 29, 2024, revealed the resident having a behavior problem related to psychosis as evidenced by delusions, refusing care, being verbally aggressive/abusive, demanding, intrusive, wandering at times, and inappropriate sexual advances to females, with an intervention to intervene…

    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 · D2026-01-26 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident involving resident-to-resident abuse between two residents (#89 and #78) was reported. The deficient practice could result in continued abuse and physical or emotional harm to residents.-Regarding Resident #89Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus.A care plan focus initiated on May 29, 2024, revealed the resident having a behavior problem related to psychosis as evidenced by delusions, refusing care, being verbally aggressive/abusive, demanding, intrusive, wandering at times, and inappropriate sexual advances to females, with an intervention to intervene as necessary to protect the rights and safety of others.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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-26 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident involving resident-to-resident abuse between two residents (#89 and #78) was investigated. The deficient practice could result in continued abuse and physical or emotional harm to residents.Findings Include:-Regarding Resident #89:Resident #89 was admitted on [DATE], with diagnoses that included mild neurocognitive disorder, major depressive disorder, iron deficiency anemia, adjustment disorder, chronic kidney disease, anemia, dysphagia, attention-deficit hyperactivity disorder, atherosclerotic heart disease, hypertension, and type 2 diabetes mellitus.A care plan focus initiated on May 29, 2024, revealed the resident having a behavior problem related to psychosis as evidenced by delusions, refusing care, being verbally aggressive/abusive, demanding, intrusive, wandering at times, and inappropriate sexual advances to females, with an intervention to intervene as necessary to protect the rights 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-17 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate regarding blood glucose monitoring for one resident (#44). The deficient practice could lead to incomplete and inaccurate medical record.-Findings Include:Resident #44 was admitted on [DATE], and re-admitted on [DATE], with diagnoses of type 1 diabetes mellitus, cerebral infarction, long term use of insulin, unspecified dementia, unspecified psychosis, and other sequelae of cerebral infarction.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #44 had a brief interview for mental status (BIMS) assessment score of 10, indicating moderate cognitive impairment. Section I revealed Resident #44 had active diagnoses of diabetes mellitus and psychotic disorder.A care plan dated June 7, 2024, revealed Resident #44 had diabetes mellitus, with interventions that included:-Diabetic medication as ordered by physician-Fasting serum…

    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 · D2025-09-05 · 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 observation, clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one resident (#3) was provided wound care in accordance with physician orders and professional standards. The deficient practice could result in wounds worsening or becoming infected. Findings include:Resident #3 was admitted to the facility on [DATE] with diagnoses that included dementia with mood disturbance, muscle weakness, and type two diabetes mellitus.Review of the care plan focus, initiated December 12, 2024, revealed that Resident #3 had pressure ulcers. The entry listed an unstageable right ischium wound with a date of November 25, 2024, and an unstageable sacral wound with a date of July 14, 2025. Interventions in place included to provide wound care as ordered by the physician.Review of physician orders revealed the following active wound care orders:Right Ischium: Cleanse with wound cleanser, pat dry, apply skin prep to surrounding wound, pack with Dakin's soaked gauze, cover…

    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 before2025-09-05 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, and policy review, the facility failed to ensure staff were maintaining proper sanitary conditions by not wearing hair nets and facial hair guards during food preparation. The deficient practice could result in infection and or contamination of food.Findings include:A kitchen observation was conducted on September 02, 2025 at 8:10 a.m. Staff #107, cook, was observed in the kitchen without a hair net. Further, Staff #51, cook, was observed in the kitchen without a hair net and with facial hair present without wearing a beard guard/net. A small pot of a green substance resembling vegetables was observed to be boiling on the stove during this time.An interview was conducted on September 02, 2025 at 2:32 p.m. with Staff #125 (Food Service Director). Staff #125 stated that while working in the kitchen staff were required to wear hair nets and facial hair guards. Staff # 125 stated that failure to wear hair nets and facial guards can cause a risk of hair in the food. Regarding staff not wearing hair nets or facial hair guards during food preparation…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 observation, staff interviews, and review of facility documentation, the facility failed to ensure call light was within reach for one resident (#27). The deficient practice could result in a preventable accident and resident not able to meet the resident's needs. Findings include: Resident #27 was admitted to the facility May 17, 2024 with two discharges to the hospital on July 22, 2024 and October 21, 24. Resident was re-admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, encephalopathy, unspecified, and bipolar disorder. Review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 06 indicating severe cognitive impairment. Further review of the MDS revealed the resident has both upper and lower impairment on both sides. A care plan dated May 29, 2024 revealed resident had activities of daily living (ADL) self-care deficit and needed assistance with…

    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
Show the remaining 14 citations
  • Potential for harm · E2024-04-17 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interviews, the facility failed to ensure that residents were were treated with dignity while dining by using disposable cutlery and dishware. The deficient practice could result in residents not able to exercise their right to be treated with respect and dignity. Findings include: During dining observation conducted on Monday, April 15, 2024 at 5:07 p.m., there were seven residents in the dining room eating dinner. The food, drinks and dessert for the seven residents were served in Styrofoam containers, cups, and bowls. The residents were also using plastic ware for utensils. In an interview One of the resident's (#80) stated that Styrofoam is used sometimes, but not all the time. An interview was conducted on April 16, 2024 at 12:35 p.m. with the dietary director (staff #85), who stated that meals were served on Styrofoam when there is an emergency situation and when the dishwasher staff calls off. He stated that the dishwashing staff (#135) called off on Monday, April 15, 2024, so he did not have anyone to wash the dinner dishes. 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-17 · 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 -An observation of the bathroom of a room (#30) conducted on April 16, 2024 at 3:28 p.m. with the maintenance director who stated that housekeeping was expected to clean bathrooms, including the walls, sink, and vents. He then poked a white substance on the bathroom vent and there was a puff of white and brown substance that came out from the vent. The maintenance director said that the white and brown substance that came out of the vent was dust and should have been cleaned. Another observation of bathroom between two different rooms was conducted with the maintenance director. The bathroom wall was stained with brown substance; and, the maintenance director stated that he would call a pest control company and have them assess the stain because he does not know what the brown stain was. He then grabbed a paper towel and touched the substance, and it crumbled under his touch. The ventilation in the bathroom had dark brown flecks; and the maintenance director stated he expected housekeeping to clean vents 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-17 · tag F0644 — pattern
    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 clinical record reviews, staff interviews and review of facility policy, the facility failed to ensure that Preadmission Screening and Resident Review (PASRR) was updated for two residents (#73 and #22); and failed to ensure level II determination was submitted for one resident (#22). The deficient practice could result in residents not receiving the care and services they needed. Findings include: -Resident #73 was admitted on [DATE] with diagnoses of bipolar disorder, major depressive disorder, severe intellectual disability. Review of the clinical record revealed that the resident had a new diagnoses of anxiety disorder on January 24, 2024. However, further review of the clinical record revealed no evidence that the PASSR Level I screening was completed after January 24, 2024. An interview was conducted on April 16, 2024 at 3:28 p.m. with the Social Services Director (staff #29), who stated that if a resident had a new psychiatric diagnosis, the PASRR needs to be updated. During the interview, 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and review of facility policy and procedure, the facility failed to ensure food items were labeled and dated when opened; and, failed to ensure that open food item was stored to maintain freshness and prevent contamination. Findings included: The initial tour of the kitchen was conducted on April 15, 2024 at 8:35 a.m. with the Dietary Director (staff #85). There was a 15-pound box of bacon, which was approximately half full in the large refrigerator. A white sheet of paper lay over the top of the bacon, but the bacon was not in a sealed bag/container. There was also approximately one fourth of shredded lettuce remaining in a two pound plastic bag that was not sealed, and the bag had no open date. The bread was located on a tray in the kitchen. A half a loaf of wheat bread was observed and there was no open date, six hamburger buns were in a plastic bag with no open date, and an open bag of twenty-three [NAME] Hawaiian Sweet Rolls did not have an open date. Staff #85 stated…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-17 · tag F0880 — failed to prevent and control infections — pattern
    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 observations, clinical record review, staff interviews, review of facility documentation and policy, the CDC (Centers for Disease Control and Prevention) and CMS (Centers for Medicare and Medicaid Services) guidance, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for one resident (#72). The deficient practice could result in transmission of multi-drug resistant organisms. Findings include: Resident #72 was admitted on [DATE] with diagnosis of hemiplegia, diabetes mellitus type 2, cerebral infarction, dementia, and gastrostomy status. A review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed BIMS (brief interview of mental status) score of 03, indicating the resident had severe cognitive impairment. The MDS also included that the resident had a gastrostomy tube. The physician order dated August 25, 2022 included for PEG (Percutaneous endoscopic gastrostomy) tube placement 18fr x 45cm. for nutritional support. The care plan dated August 28, 2022…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-01 · tag F0727 — failed to provide required RN coverage — pattern
    Have 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 staff interviews and facility documentation, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The deficient practice has the potential to affect resident care. Findings include: Review of the facility's staffing documentation revealed there was not a registered nurse on duty for 8 consecutive hours for the month of April and May 2022 on the following dates: April 8 April 20 April 22 April 27 April 29 An interview was conducted on November 30, 2022 at 2:23 p.m. with the Executive Director (ED/staff #79), who stated that the facility was using registry staff during the month of May 2022. The ED stated that he would try to identify the RNs that worked on the above dates and provide invoices to show the numbers of hours worked. An interview was conducted on December 1, 2022 at 9:30 a.m. with the Director of Training and Development (staff #92). She stated that she reviewed the time cards/invoices and that she did not have any documentation of an RN working on April 8, 20, 27, and 29, 2022. She also stated 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-01 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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, resident and staff interviews, and facility policy and procedure, the facility failed to assist one resident (#4) with a request to transfer to another facility within a timely manner. The sample size was 3. The deficient practice could result in residents being denied the right to make their own choices. Findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses that included Psoriatic Arthritis Mutilans, contracture of muscle, and chronic pain syndrome. The initial psychiatric evaluation dated August 4, 2022 revealed the resident plan was to look for another place to live. The resident endorses anxiety over the future. The resident reported a desire to leave this facility and find a new place to live. Coordinated and consulted with nursing staff, and social services regarding assessment. Review of the occupational therapy Discharge summary dated [DATE] revealed the resident was to discharge to long-term care. Review of 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-01 · 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 clinical record review, staff interviews, and review of policy, the facility failed to ensure that one out of two sampled residents (#44) was accurately assessed and referred for Level II Pre-admission and Resident Review (PASRR) services. The deficient practice increases the occurrence of improper placement into a nursing home and/or may fail to provide residents with necessary services. Findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, adjustment disorder, and affective mood disorder. However, review of the Level I PASRR dated 01/20/21 revealed the resident did not have a primary diagnosis of mental illnesses and that no referral was necessary for Level II services. A behavioral symptoms care plan dated 01/31/21 related to schizoaffective disorder behaviors, including episodes of refusing care, easily agitated, yelling at staff, verbal aggression/cursing, and excessive call light use. The goal was for the resident to comply…

    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 before2022-12-01 · 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 clinical record review, staff interviews, and review of policy, the facility failed to ensure a care plan intervention and policy was implemented for one sampled resident (#89) regarding a transfer to a wheelchair. The deficient practice could result in potential harm to residents. Findings include: Resident #89 was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, adjustment disorder, and polyosteoarthritis. A review of the care plan initiated on 11/12/21 revealed a behavior problem as evidenced by being verbally abusive to staff, self isolates, and refusing to wear an ID bracelet. The goal was that the resident would not have any complications secondary to not wearing an ID band daily, and will not harm themselves or others secondary to their behaviors. Interventions included providing care in pairs. Review of the Health Status Note dated 05/27/22 at 6:42 PM revealed the resident was upset and stated she was put in 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
  • Potential for harm · D2022-12-01 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 policy reviews, the facility failed to ensure that the necessary behavioral health care and services were provided to sampled one resident (#90). The deficient practice could result in residents not receiving the necessary behavioral health care and services they require to prevent self-harm. Findings include: Resident #90 admitted to the facility 02/09/22 with diagnoses that included malignant neoplasm of vulva, adjustment disorder with depressed mood and noncompliance with other medical treatment and regimen. The physician orders included: -Cleanse perineal area with no-rinse foaming cleanser, apply metronidazole sprinkles (antibiotic/amebicide/antiprotozoal), apply petroleum jelly, cover non-adherent gauze cover with abdominal non-stick pad two times per day for wound care. Order date 02/09/22. -metronidazole tablet 500 milligrams (mg), applied to perineum topically one time a day for perineum wound until 02/23/22. Order date 02/10/22. -Perineal area:…

    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 · D2022-12-01 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#84) drug regimen was free of unnecessary drugs, by administering a medication outside of the physician ordered parameters. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #84 was admitted on [DATE] with diagnoses of Schizoaffective Disorder Bipolar type, Bipolar disorder current episode hypomanic, and chronic obstructive pulmonary disease with acute exacerbation. Review of the care plan initiated on August 10, 2022 revealed the resident had congestive heart failure and hypertension. Interventions included giving cardiac medications as ordered, monitoring vital signs routinely and as needed, and notifying the physician of significant abnormalities. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 14 on the Brief Interview for Mental Status, indicating the resident had…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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 policies and procedures, the facility failed to ensure identification and monitoring of target behaviors for one resident (#32) receiving psychotropic medications. The sample size was 5. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #32 was readmitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, and unspecified liver disease. The admission Minimum Data Set (MDS) assessment dated [DATE] included a diagnosis of dementia. An anticonvulsant care plan revised on 11/16/21 related to a mood disorder secondary to dementia had a goal to be free from discomfort or adverse reactions related to anticonvulsant therapy. Interventions stated to administer medications as ordered by the physician and to monitor for side effects. A care plan revised 02/14/22…

    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 · D2022-12-01 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure the medication error rate was less than 5% by failing to ensure medications were not crushed without a physician's order for one resident (#37). The medication error rate was 8%. The deficient practice could result in further medication errors. Findings include: Resident #37 admitted to the facility 10/23/19 with diagnoses including schizoaffective disorder, polyosteoarthritis and Alzheimer's disease. During a medication administration observation conducted on 11/29/22 at 7:05 a.m., a Licensed Practical Nurse (LPN/staff #23) was observed to crush one tablet of Quetiapine Fumarate (antipsychotic medication) 25 milligrams (mg) and one-half tablet of morphine sulfate (narcotic pain medication) 7.5 mg. The nurse was then observed to mix the crushed medications with applesauce and administer the medications to resident #37. A physician order dated 09/15/21 included Quetiapine Fumarate 25 mg; give one time daily for schizoaffective disorder, bipolar type. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-12-01 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, staff interview, and facility policy and procedure, the facility failed to ensure that nurse staffing information was posted on a daily basis that included the number of each type of licensed and unlicensed nursing staff working on each shift and the actual hours worked. The deficient practice resulted in information not being readily available to residents and visitors. Findings include: Review of the Daily Staff Posting dated October 7, 2022 and November 5, 2022 revealed that the number of each type of licensed and unlicensed nursing staff working on each shift and the actual hours worked were not included. On November 29, 2022 at 11:53 a.m., the Daily Staff Posting was observed hanging on the wall to the right of the nurses' station. The posting contained the census, and the total number of work hours scheduled for each category of licensed and unlicensed staff, but did not contain the number of each type of licensed and unlicensed staff working each shift or the actual hours worked or the correct date. An interview was conducted on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services 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

$75,868 in federal fines across 3 penalties.

  • $23,000 — penalty dated 2026-04-15
  • $44,850 — penalty dated 2025-12-17
  • $8,018 — penalty dated 2024-08-23

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.

Who owns this facility

Owner / managerTypeRoleShareSince
SRCV HAVEN, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 08/20/2002
SRCV, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/16/2002
NEVINS, HARVEYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 08/16/2002
HUNT, JAYSONIndividualW-2 MANAGING EMPLOYEEsince 11/30/2015

CMS files one row per role, so the 8 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

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 035062. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, 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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