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Haven Of Phoenix

4202 North 20th Avenue, Phoenix, AZ 85015 · For profit - Corporation · 114 certified beds · (602) 264-3824 Medicare & Medicaid certified

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Flagged for abuse1 actual-harm citation$8,278 in federal fines
Insights

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

Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,278 in federal fines (most recent 2025-12-16)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4220 N 20th Ave · (602) 889-9401 · Call to confirm hours
Pharmacy
4040 N 19th Ave · (602) 265-3167 · Call to confirm hours
Grocery
4040 N 19th Ave · (602) 265-3167 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1831 W Indian School Rd · (602) 850-1020

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 4 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 rating4★
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 increased5.0%10.7%15.4%better
Long-stay residents who lose too much weight5.2%5.3%5.4%typical
Long-stay residents with a catheter left in their bladder0.4%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms6.5%3.9%6.5%typical
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 injury1.2%2.1%3.3%better
Long-stay residents whose ability to walk worsened4.7%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.5%21.0%18.9%worse
Long-stay residents given the seasonal flu vaccine97.3%94.6%95.3%typical
Long-stay residents with pressure ulcers0.9%4.4%4.7%better
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 table1.4%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.1%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine93.4%87.3%79.4%better
Short-stay residents rehospitalized after admission31.1%23.7%22.6%worse
Short-stay residents with an outpatient ER visit10.6%10.4%12.0%better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

56.0% 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 131 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.0%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
63.9%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 63.9% 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 36 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.0%CMS range 47.9–63.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.4–14.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge58.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 4.1–10.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.53
RN hours/ resident / day
0.77
LPN hours/ resident / day
1.93
Aide hours/ resident / day
3.23
Total nurse hours/ resident / day
0.33
RN hoursweekends
37.4%
Total nursing turnover
41.7%
RN turnover

How full it usually is: this home is certified for 114 beds and averages 106.9 residents a day — about 94% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.93 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.84 hrs/resident/day on weekends vs 3.38 on weekdays — 16% thinner on weekends. RN hours go from 0.61 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% 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

6
deficiencies at the latest standard inspection (2026-05-06)
4
at the previous standard inspection (2025-01-24)

Deficiencies are more than at the previous inspection — worsening. 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.

20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · Gcited before2025-12-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff and resident interviews, and review of the facility policy and procedures, the facility failed to ensure the safety of one resident (#5) by not properly securing the resident and failing to maintain a safe speed during transport. The deficient practice could result in residents being physically injured.Findings include:Resident #5 was admitted to the facility on [DATE], and discharged on December 28, 2023, with a diagnosis including infection and inflammatory reaction due to internal left knee prosthesis, subsequent encounter, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end-stage renal disease, and dependence on renal dialysis.Review of the Care Plan, date-initiated December 18, 2023, revealed a focus for fall risk related to generalized weakness. Interventions included anticipating and meeting the residents' needs and following the facility's fall protocol. Further review of the care plan identified a focus for anticoagulant therapy. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-06 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    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 a review of records, observation, interviews, policies and procedures, the facility failed to ensure that two residents (#122 and #163) were not abused by another resident (#121 and #60) out of 11 sampled residents. The Universe was 99. The deficient practice could lead to physical and psychosocial harm to residents.Regarding the altercation between Resident #121 and Resident #122-Regarding #121, (Alleged Perpetrator) Resident #121 was re-admitted to the facility on [DATE], with diagnoses that included encephalopathy, anxiety, and bipolar disorder.A Physical Aggression incident report dated April 27, 2026, at 5:35 p.m., revealed that a Nurse was notified of an incident involving Resident #121 (alleged perpetrator) and #122 (alleged victim), who shared a room. The note included that the nurse entered the room and observed Resident #121 screaming it's my walker, and physically hitting Resident #122 in the right upper extremity. The note indicated that the residents were separated, and Resident #121 was…

    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 · E2026-05-06 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that medications were administered as ordered for two of five sampled residents (Resident #32 and #56). The deficient practice could result in resident's pain not being controlled.Regarding Resident #32: Resident #32 was readmitted to the facility on [DATE], with a diagnosis that included schizoaffective disorder, bipolar type; bipolar disorder; major depressive disorder; and anxiety disorder. A care plan focus dated February 24, 2025, revealed Resident #32 had polyneuropathy pain. Interventions included that the staff were to anticipate his need for pain relief and respond as soon as possible. A physician's order dated October 8, 2025, revealed Resident #32 is to take one 325 mg tablet of oxycodone-acetaminophen every 5 hours as needed for pain levels of 6 to 10. A quarterly minimum data set (MDS) assessment dated [DATE], revealed that Resident #32 had a BIMS (brief interview of mental status) score of 15,…

    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 · Ecited before2026-05-06 · 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 observation, review of the clinical records, staff interviews, review of the Blood Glucose Monitoring System User's Guide, and review of the facility's policy and procedure, the facility failed to ensure that staff conducted proper hand sanitizing during a meal service and infection control procedures were performed after a point of care testing for blood sugar check, for one resident (#164) to help prevent a transmission of infections according to acceptable clinical standards of practice. The census was 99. The deficient practice could result in the spread of infectious diseases to other residents and could place the residents at risk for infection.Findings include: -Regarding Following Hand Hygiene: An observation of residents in the dining room was conducted on April 4, 2026 at 7:38 AM. There were a total of five Residents having breakfast and one staff member (#37) a Certified Nursing Assistant (CNA) assisting the residents. Each of the Residents were sitting at their own table. Residents had their…

    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 · D2026-05-06 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of the clinical records, staff interviews, and from the Arizona Health Care Cost Containment System, the Pre-admission Screening and Resident Review (PASRR), the facility failed to ensure the PASARR (pre-admission screening and resident review) was updated appropriately and accurately submitted, when applicable, for one resident (#32). The census was 99. The deficient practice could result in residents' medically related social and emotional needs not being met. The census was 99.Findings include:Resident #32 was readmitted to the facility on [DATE], with the diagnoses that included Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. A review of the Minimum Data Set (MDS) 5-day assessment dated [DATE], revealed that the Resident's Brief Interview for Mental Status (BIMS) was not assessed. The Quarterly MDS assessment dated [DATE], revealed a BIMS score of 15.0, indicating that the Resident was cognitively intact. The assessment also revealed that no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-06 · tag F0697 — failed to manage pain — isolated
    Provide 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 that pain management was provided to one resident (#137) consistent with professional standards of practice, and the resident's comprehensive person-centered care plan. The deficient practice could place the resident's health at risk by not adequately treating the resident's pain.Findings include:Resident #137 was admitted to the facility on [DATE], with diagnoses that included aftercare following a joint replacement surgery and fibromyalgia.The assessment for Brief Interview for Mental Status (BIMS) dated 05/03/2026, revealed a score of 12.0, indicating that the Resident was moderately impaired.A review of the physician's pain medication orders revealed an order for Hydrocodone-Acetaminophen oral tablet 5-325 MG (milligram) give 1 tablet by mouth every 4 hours as needed for pain level of 4-6 and give 2 tablets by mouth every 4 hours as needed for pain level of 7-10; and Ibuprofen oral tablet 200 MG give 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-06 · tag F0732 — isolated
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and policy documentation, the facility failed to ensure that the daily nurse staffing information posted included all data requirements. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information. Findings include:An observation on May 3, 2026, at 6:59 AM, of the staff postings for May 3, 2026, included the number of certified nursing assistants (CNAs), the number of restorative nursing assistants (RNAs), the number of registered nurses (RNs), the number of licensed practical nurses (LPNs), and the number of medication technicians, categorized by shift. There was no evidence of an area where the actual hours worked by staff could be completed. A review of randomly chosen days of staff postings compared with the staff assignment sheets revealed that none of the staff postings matched the actual number of staffs that worked.Review of the Daily Staffing reports revealed the following missing data requirements.- May 23, 2025, revealed no evidence of the calculation of actual hours…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-06 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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 one (#56) of 29 sampled residents. The deficient practice could result in harm to the residents, and/or visitors who have access to medications.Findings include:Resident #56 was admitted to the facility on [DATE], with diagnoses that included dysphagia, gastro-esophageal reflux disease without esophagitis, hypertension, and anxiety.An admission evaluation record dated November 18, 2026, revealed that the resident did not desire to self-administer drugs.A quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition.There was no evidence in the progress notes of an interdisciplinary team (IDT) meeting related to medication self-administration.During an initial observation of Resident #56's room on May 03, 2026, at 08.47 a.m., a bottle of Soursop [NAME] supplement for gut…

    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 · E2025-01-24 · tag F0680 — pattern
    Ensure the activities program is directed by a qualified professional.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on personnel file review, staff interviews, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. This deficient practice could have resulted in the activities provided not meeting the assessed needs of the residents. Findings Include: A review of the personnel file for the role of activity manager (AD/Staff #111) was conducted on May 21, 2024. However, the review did not reveal evidence that staff #111 possessed the qualifications required for the role of activities director. An interview was conducted on January 23, 2025, at 9:38 A.M. with staff #111, Activities Director. Staff #111 stated that she had been working at the facility as an Activities Director for several years. She stated that as an activities manager, she visited the residents, providing them with menus that included the activities of the day as well as the food menu. She also stated that she oversaw the smoke break. An interview was conducted on January 23, 2025, at 9:43 A.M. with staff #41, Human Resources. She was asked…

    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 before2025-01-24 · 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, facility documents, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#395) was free from neglect, by failing to ensure the resident was administered care and services to meet his needs. The deficient practice could result in residents not being provided the necessary services. Findings include: Resident #395 was admitted to the facility on [DATE] with diagnosis that included osteomyelitis, sepsis, methicillin resistant staphylococcus aureus infection, pressure ulcer of sacral region stage 4, quadriplegia, extended spectrum beta lactamase resistance, urinary tract infection, protein calorie malnutrition, and major depressive disorder. A care plan initiated on [DATE] revealed that the resident had bowel incontinence related to inability to control bowels. Interventions indicated included check resident every two hours and assist with toileting as needed. A laboratory result dated [DATE] indicated that Coranavirus was not detected.…

    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 · D2025-01-24 · 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 observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one of 21 sampled residents (#82) had a referral for a Level II PASRR (pre-admission screening and resident review).The deficient practice could result in the resident not receiving specialized services needed. Findings include: Resident #82 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, anxiety disorder, post- traumatic stress disorder, and depression. Review of the clinical record revealed a Level I pre-admission screening and resident review (PASSR) dated November 27, 2024. Upon review of the document, the box indicating that a referral for Level II determination for mental illness (MI) only was selected. There was also boxes that were selected indicating that the resident had major depression, anxiety disorder, and post-traumatic stress disorder (PTSD). The form was signed and dated. Additional review of the clinical record revealed no evidence that 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
Show the remaining 9 citations
  • Potential for harm · Dcited before2025-01-24 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and process, the facility failed to ensure that care was provided according to professional standards and that the resident's basic needs are being met for one resident (#42). The deficient practice could result in residents not being provided the care needed to maintain or improve health. Resident #42 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis, cystitis, major depressive disorder, and multiple myeloma not having achieved remission. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating intact cognition. Section I revealed the resident had an active diagnosis of diabetes mellitus. A physician order dated June 18, 2021, indicated for Humalog Solution 100 unit/ml (Insulin Lispro), to inject as per sliding scale, subcutaneously before meals and at bedtime for diabetes mellitus: If blood sugar…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-13 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on documentation, staff interviews, and the facility policy and process, the facility failed to ensure that care was provided according to professional standards and that the resident's basic needs are being met for one resident (#10). The deficient practice could result in residents not being provided the care needed to maintain or improve health. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses that included acute chronic heart failure, pleural effusion, urinary tract infection, cellulitis of left lower limb, severe sepsis without septic shock, hypoxemia, and hypokalemia. The order summary revealed an order dated: -[DATE] for oxygen as needed (PRN) at 0-5 liters per a minute to keep oxygen saturation above 90% every 8 hours as needed for oxygen therapy. -[DATE] for oxygen at 0-5 liters per minute as needed to keep saturation above 90% every shift for oxygen therapy. -[DATE] vital signs per facility protocol -[DATE] for full code CPR Review of the care plan dated [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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-20 · 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 documentation, staff interviews and the facility policy and procedures, the facility failed to report an allegation of abuse to the state survey agency and failed to complete and submit a 5-day written investigation timely. The deficient practice could result in residents not being protected and being abused. Findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses that included hypertension, schizophrenia, multiple sclerosis, and anxiety. The care plan dated April 21, 2022 revealed that the resident had an impaired cognitive function. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion and requires approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, written lists, and instructions. Resident #8 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, unspecified…

    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 before2024-08-20 · 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 record review, staff interviews, and the facility policy and procedures, the facility failed to ensure residents (#26, #25, and #3) were provided with the appropriate level of supervision. The deficient practice could result in the personal space of residents not being respected. Findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, chronic obstructive pulmonary disease, and hypertensive chronic kidney disease. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. The care plan dated July 23, 2024 revealed an impaired cognitive function/dementia or impaired thought process related to sexual advances towards staff. Interventions included to monitor/document/report to the medical doctor any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty…

    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 · E2023-09-08 · 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 The facility failed to ensure food was properly stored, prepared, handled and served according to professional standards. Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value. Findings include: During the initial tour of the kitchen conducted on September 5, 2023 at 8:26 AM, with the Food Service Manager (#38), the following observations were made in the large walk-in refrigerator and freezer and the dry storage: -Two boiled eggs in a container with in by date of September 5, with no use by date or year. -a package of bacon bits with a date of August 25, 2023 and no use by date. -10 ham slices in dated September 4 with no use by date or year. -a four-pound bus tub of kale opened and exposed to air with ice chips on top of the kale. Per staff (#38) this was done to keep the kale fresh, but should have been stored 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-08 · 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 policy, the facility failed to ensure resident do not sustain preventable accidents including falls resulting in major injury. Failure to ensure this resulted increased morbidity and mortality. Findings include: Resident #157 was admitted with diagnoses of dementia, need for assistance with personal care, and cognitive communication deficit. A Quarterly Minimum Data Set (MDS) dated [DATE] included that a Brief Interview for Mental Status (BIMS) score of 5 which indicates that the resident was severely cognitively impaired. This document included that this person required 2+ person extensive physical assistance with transfers. A care plan dated 6/14/22 included that the resident has an Activities of Daily Living (ADL) self care performance deficit related to diagnoses of COPD, Dementia and weakness. This document included that the resident required staff participation in transfers. A health status note dated 2/27/23 included that patient slid out 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-08 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, facility recipes, and policy review, the facility failed to ensure the nutritive value of puree food. The deficient practice could result in residents receiving food with altered nutritive value. Findings include: During an observation conducted on September 6, 2023 at 11:42 AM in the kitchen, the cook (staff #15) was observed preparing puree food for two residents. Staff (#15) placed several large spoons of chicken and broccoli into a blender, added hot chicken broth, and blended the mixture. Staff (#15) proceeded to place the broccoli and chicken mixture into a steam pan to serve without tasting. Staff (#15) stated the chicken broccoli mixture was ready to serve. Staff (#15) was asked how did he know that the texture was at the right consistency and texture for a pureed diet. Staff (#15) stated he had been doing this work for a long time and could tell by its appearance. A request was made to taste the chicken broccoli mixture and was also tasted by Food Service Director (staff #38). the chicken broccoli mixture was noted to be gritty, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-08 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food brought by visitors and family was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value. Findings include: During the initial tour of the kitchen conducted on September 5, 2023 at 8:26 AM, with the Food Service Manager (#38), the following observations were made in the large walk-in refrigerator and freezer. -a package of Delimex beef carne de res taquitos open exposed to air belonging to resident (#68). Per staff (#38) residents food should not be kept unopened in the facility freezer. -an open 48 fl oz container of salted caramel ice cream belonging to resident (#68). Per staff (#38) residents' food should not be kept unopened in the facility freezer. - a open 48 fl oz container of Blue-Ribbon Chocolate and Vanilla ice cream belonging to resident (#65). Per staff (#38) residents' food should not be kept unopened in the facility freezer. An interview was conducted on September 8, 2023 09:10…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that infection control standards were maintained regarding hand hygiene and donning gloves by an LPN (Licensed Practical Nurse/staff #74) during medication administration. The deficient practice could result in the spread of infection to residents. Findings include: An observation during medication administration conducted on September 7, 2023 from 9:20 a.m. to 9:45 a.m. with an LPN (staff #74), the following was observed: -Staff #74 was observed administering medications which were handled with their bare hands. The LPN was observed popping pills out of the blister pack into her bare ungloved hand. Each resident was observed being administered the medication after it had been handled by staff #74. This occurred three times during the observation. -Staff #74 provided medications to multiple residents without sanitizing their hands between residents, after touching the residents and various objects in the resident's rooms, such as tray tables and bedding. During an interview…

    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

“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

$8,278 in federal fines across 1 penalty.

  • $8,278 — penalty dated 2025-12-16

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 →

RatingThis homeChain avg
Overall 3 of 52.7+0.3 vs chain
Health inspection 2 of 52.0≈ chain avg
Staffing 3 of 52.3+0.7 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 19 homes this chain runs (chain average 2.7★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
SEASTRAND, JASONIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2016
WEST, CHRISTIANIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2016
HAVEN HEALTH PROPERTIES LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 06/01/2016
HAVEN PHOENIX REAL ESTATE LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 06/01/2016
HEALTH GROUP MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/25/2024
AHMED, BAHALEDINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2016
FRAGOSO, LINDSAYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/10/2021
GANDHI, HEMANGIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
GREINER, RUSSELLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/16/2023
KOKER, SHELLYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/05/2026
ROBERTSON, BRETTIndividualADP OF THE SNFsince 12/18/2024
SAMUELIAN, ROBERTIndividualADP OF THE SNFsince 12/18/2024
SAMUELIAN, SPENCERIndividualADP OF THE SNFsince 12/18/2024
SAMUELIAN, STEPHENIndividualADP OF THE SNFsince 12/18/2024

CMS files one row per role, so the 26 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$14.1M
Net patient revenuemost recent cost report
+3.9%
Operating marginrevenue minus expenses
$877K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 7%Other / private 26%

This home reported $877K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$360per resident / day
operating cost
$10,951per month
≈ monthly operating cost
$375per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AZ

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arizona Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 035107. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-06, 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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