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Haven Of Safford

1933 Peppertree Drive, Safford, AZ 85546 · For profit - Limited Liability company · 106 certified beds · (928) 428-4910 Medicare & Medicaid certified

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Flagged for abuse1 actual-harm citation$15,210 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • 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 abuse, neglect, or exploitation citations (F0600, F0602) — most recent Aug 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 1 actual-harm citation
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $15,210 in federal fines (most recent 2026-02-10)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1765 S 20th Ave · (928) 424-1600 · Call to confirm hours
Pharmacy
2035 W Relation St · (928) 428-3605 · Call to confirm hours
Grocery
Safeway1.5 mi
2125 W US Highway 70 · (928) 428-2771 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
2580 S 17th Ave · (928) 250-8997

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
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 increased6.8%10.7%15.4%better
Long-stay residents who lose too much weight6.2%5.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.8%0.9%better
Long-stay residents with a urinary tract infection0.0%1.2%2.0%better
Long-stay residents with depressive symptoms0.6%3.9%6.5%better
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.9%2.1%3.3%worse
Long-stay residents whose ability to walk worsened8.8%12.8%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.7%21.0%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%94.6%95.3%typical
Long-stay residents with pressure ulcers2.3%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control19.9%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table13.5%10.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.7%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine94.4%87.3%79.4%better
Short-stay residents rehospitalized after admission21.0%23.7%22.6%typical
Short-stay residents with an outpatient ER visit4.8%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.

65.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 77 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.3%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
62.2%U.S. median 56.6%
Met the expected recovery
0.11U.S. median 0.30
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 62.2% 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 37 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 0.11 therapist hours per resident per day in 2025Q4 — more than 7% of the 13,714 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 14% — 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 SNF65.3%CMS range 56.4–73.251.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.0–15.310.7%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 discharge62.2%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 discharge67.6%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 discharge59.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 settingnot reported — The number of residents or resident stays is too small to report. 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 discharge95.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.6%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 hospitalization6.4%CMS range 2.9–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.711.02Oct 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

1.25
RN hours/ resident / day
0.12
LPN hours/ resident / day
1.97
Aide hours/ resident / day
3.33
Total nurse hours/ resident / day
0.79
RN hoursweekends
42.5%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 106 beds and averages 73.9 residents a day — about 70% occupied, or roughly 32 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.25 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 2.71 hrs/resident/day on weekends vs 3.11 on weekdays — 13% thinner on weekends. RN hours go from 1.13 to 0.78 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% 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

3 ↓
deficiencies at the latest standard inspection (2026-08-05)
7
at the previous standard inspection (2024-11-08)

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.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Actual harm · Gcited before2026-02-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and policy review, the facility failed to protect the rights of two residents (#10) and (#20) to be free from abuse by another Resident (#50). This deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #10 (Victim #1) was admitted to the facility on [DATE], with diagnosis that include hemiplegia, cerebral vascular accident, dementia, urinary tract infection, diabetes mellitus type 2, and sepsis. Review of the Quarterly Minimum Data Set (MDS) assessment dated November December 8, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. A review of the care-plan for Resident #10 revealed the resident has a behavior problem related to impaired cognitive function, impaired safety awareness, and verbal behaviors with noted interventions of anticipate and meet the resident's needs, allow…

    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 · E2026-08-05 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, facility documentation, staffing records, and policy review, the facility failed to ensure sufficient nursing staff were available to provide care and services to meet residents' needs. The deficient practice could result in delayed or unmet care needs for residents requiring staff assistance.Findings include:Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing during three reporting quarters in 2025. The facility assessment dated [DATE], revealed that the facility was licensed to provide care for 106 residents and had an average daily census of 70 to 80 residents. The average census included 10 to 25 short-stay residents and 30 to 45 long-stay residents. The facility assessment further identified 65 residents who required at least two-person assistance.The facility assessment staffing plan identified the following nursing staffing structure:Full-time Director of Nursing…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has no plan of correction
  • Potential for harm · Dcited before2026-08-05 · 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 applicable policies and procedures, the facility failed to ensure two of five sampled resident's (Resident #75 and Resident #52) right to be free from physical abuse by another resident (Resident #43 and Resident #6). The deficient practice had the potential to result in additional incidents of abuse and failure to take appropriate measures to protect the residents. Findings included: Regarding resident #75 and Resident #43: -Regarding Resident #75 Resident #75 was admitted to the facility on [DATE] with pertinent diagnoses including dementia, chronic heart disease, anxiety disorder, chronic pain syndrome, visual hallucinations, generalized muscle weakness, and other related comorbidities. A care plan dated June 26, 2025, revealed that Resident #75 had impaired cognitive function related to dementia, which affected her ability to make her own decisions, with noted interventions to reduce distractions, such as television…

    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 no plan of correction
  • Potential for harm · Dcited before2026-08-05 · 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 record review, resident interview, staff interview and facility policy and procedures the facility failed to ensure the facility policy for abuse was followed for 1 of 5 sampled residents. The deficient practice could result in allegations of abuse not being accurately identified, reported, investigated, and addressed, thereby placing residents at risk for further abuse, physical harm, pain, mental anguish, or emotional distress. Findings include: - Regarding resident #6: Resident #6 (Perpetrator) was admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, hypertension, a history of fractures and malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had significant cognitive impairment. The care-plan revealed the resident has a behavior problem related to impaired safety awareness, verbal behavior, and physically aggressive behaviors, with a goal of maintain…

    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 no plan of correction
  • Potential for harm · D2026-02-10 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and policy review, the facility failed to protect the rights of a resident (#10) to be free from misappropriation from staff. This deficient practice could result in further incidents of staff to resident abuse. Findings Include: -Resident #10 was admitted to the facility on [DATE], with diagnosis that include hemiplegia, cerebral vascular accident, dementia, urinary tract infection, diabetes mellitus type 2, and sepsis. Review of the Quarterly Minimum Data Set (MDS) assessment dated November December 8, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. A review of the care-plan for resident #10 revealed the resident is at risk for functional care deficits and functional mobility limitations with noted interventions of requiring assistance with ambulation, and require supervision and assistance with various activities of daily living.…

    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 before2026-01-09 · 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 record review, observations, interviews, and review of the facility's policies and procedures the facility failed to implement their abuse prohibition policy when there was an allegation of sexual abuse of one resident (#5). The deficient practice could lead to residents not being protected from abuse.Findings include:Resident #5 was admitted to the facility on [DATE] with diagnoses that include early onset Alzheimer's disease, aphasia, and depression.A quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #5 had severe cognitive impairment.A care plan, initiated on August 11, 2025 indicated Resident #5 had behavior problems that included poor safety awareness, wandering, and exit seeking. Interventions included intervening as necessary to protect the rights and safety of others.The same care plan was updated on January 5, 2026 to include lifting shirt exposing breasts at times. However, there were no revisions made 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · 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 record review, interviews, and review of the facility's policies and procedures the facility failed to report an allegation of sexual abuse of one resident (#5). The deficient practice could lead to residents not being protected from abuse.Findings include:Resident #5 was admitted to the facility on [DATE] with diagnoses that include early onset Alzheimer's disease, aphasia, and depression.A quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #5 had severe cognitive impairment.A care plan, initiated on August 11, 2025 indicated Resident #5 had behavior problems that included poor safety awareness, wandering, and exit seeking. Interventions included intervening as necessary to protect the rights and safety of others.The same care plan was updated on January 5, 2026 to include lifting shirt exposing breasts at times. However, there were no revisions made to the interventions related the Resident #5's behaviors. Review 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · 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 record review, observations, interviews, and review of the facility's policies and procedures, the facility failed to thoroughly investigate allegations of abuse for one resident (#5) and take steps to correct it. The deficient practice could lead to residents being subjected to continued abuse. Findings include:Resident #5 was admitted to the facility on [DATE] with diagnoses that include early onset Alzheimer's disease, aphasia, and depression.A quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #5 had severe cognitive impairment.A care plan, initiated on August 11, 2025 indicated Resident #5 had behavior problems that included poor safety awareness, wandering, and exit seeking. Interventions included intervening as necessary to protect the rights and safety of others.The same care plan was updated on January 5, 2026 to include lifting shirt exposing breasts at times. However, there were no revisions made to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-09 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, facility documentation, and policy, the facility failed to ensure that safeguards and systems were in place to ensure accurate reconciliation and accounting for all controlled substances for one of three medication carts sampled. The deficient practice could result in inventory loss and potential diversion. A medication cart observation was conducted on December 9, 2025, at 10:24 a.m. with Licensed Practical Nurse (LPN/Staff # 46). Photographic images were obtained, with Staff # 46 present, of the Progressive Care Units (PCU) Narcotic Count Reconciliation Sheets. The narcotic sheets were reviewed with Staff # 46 for the months of October 2025 to December 2025. Staff #46 identified multiple entries with either no nurse signatures or only one nurse signature. The review of the Narcotic Count Reconciliation Sheet was conducted for two weeks, October 1-14, 2025 revealed the following:-Two nurses' signatures were not present on 2 shifts between October 1 and 14, 2025.-One nurse's signature was not present on 9 shifts between October 1 and 14,…

    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 · E2025-12-09 · 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

    Based on a review of records and staff interviews, it was revealed that the facility failed to follow infection control guidelines for laundry services, medication preparation, and medication storage. This deficient practice can result in the failure to prevent and control infection transmission amongst a vulnerable population.Findings include:-Regarding the Laundry AreaRe: Laundry RoomAn observation of the facility's laundry room was conducted on December 9, 2025, at 10:15 a.m., with a laundry services employee (Staff #16). During the observation, the following deficiencies were identified on the dirty (soiled) side of the laundry department:1. The linen cart designated for dirty items contained loose articles of clothing that were uncovered.2. Two folded white blankets with visible debris and areas of dark soiling were located underneath both the washer and dryer.3. A blue and white fitted sheet was uncovered inside a gray mobile storage container.4. Two of the three yellow mobile storage containers were uncovered, containing soiled laundry. The third yellow container had its lid…

    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 · Dcited before2025-12-09 · 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, interviews, review of facility documentation and policies, the facility failed to protect the rights of one resident (# 76) to be free from verbal abuse by a staff member (Staff # 30). The deficient practice has the potential to violate the resident's right to safety and prevent further harm. Based on clinical record review, interviews, review of facility documentation and policies, the facility failed to protect the rights of one resident (# 76) to be free from verbal abuse by a staff member (Staff # 30). The deficient practice has the potential to violate the resident's right to safety and prevent further harm. Findings include,Resident #76 was originally admitted to the facility on [DATE], with the most recent admission date being July 19, 2025, with diagnoses that included cerebral infarction, unspecified; legal blindness, as defined in USA; chronic pain syndrome, adjustment disorder with mixed anxiety and depressed mood, other bipolar disorder, restlessness and agitation,…

    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
Show the remaining 10 citations
  • Potential for harm · D2024-11-08 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and family interviews, and facility documents and policy, the facility failed to ensure a resident's privacy was maintained during medication administration for one resident (resident # 23). This deficient practice could result in further violations of resident privacy. Findings include: Resident #23 was initially admitted on [DATE] and re-admitted on [DATE] with diagnosis including Non-St Elevation (Nstemi) Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Atherosclerotic Heart Disease, and Gastrointestinal Hemorrhage. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating mild cognitive impairement. An interview was conducted on November 6, 2024 at 8:30 a.m. with a Registered Nurse and Unit Manager, (RN/Staff #26), where Staff #26 explained their expectations with respecting a resident's absolute privacy, that during patient care, doors should be…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to ensure that one resident (#128) was free from abuse from another resident (#66). This deficient practice could result in further instances of abuse. Findings include: -Resident #128 was admitted at the facility on December 4, 2023 with diagnoses that included dementia, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated on June 11, 2024 revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. Review of care plan initially dated on February 26, 2024 and revised on August 1, 2024 revealed that resident #128 use antidepressant medication. The interventions included to monitor/document/report to provider as needed ongoing signs and symptoms of depression which included fear of being alone with others, attention seeking, concern with body functions, anxiety, and constant reassurance.…

    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 before2024-11-08 · 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 reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to follow their abuse policy for one resident. (#128) The deficient practice can result in further incidents of abuse. Findings include: -Resident #128 was admitted at the facility on December 4, 2023 with diagnoses that included dementia, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated on June 11, 2024 revealed the resident had a BIMS score of 4.0, which indicated severe cognitive impairment. Review of care plan initially dated on February 26, 2024 and revised on August 1, 2024 revealed that resident #128 use antidepressant medication. The interventions included to monitor/document/report to provider as needed ongoing signs and symptoms of depression which included fear of being alone with others, attention seeking, concern with body functions, anxiety, and constant reassurance. -Resident #66 (alleged…

    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 before2024-11-08 · 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 reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to ensure an incident of abuse was reported to the state agency. This deficient practice can result in further incidents of abuse not being reported in accordance with professional standards. Findings include: -Resident #128 was admitted at the facility on December 4, 2023 with diagnoses that included dementia, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated on June 11, 2024 revealed the resident had a BIMS score of 4.0, which indicated severe cognitive impairment. Review of care plan initially dated on February 26, 2024 and revised on August 1, 2024 revealed that resident #128 use antidepressant medication. The interventions included to monitor/document/report to provider as needed ongoing signs and symptoms of depression which included fear of being alone with others, attention seeking, concern with body…

    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 before2024-11-08 · 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 reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to investigate an allegation of abuse. This deficient practice could result in further incidents of resident abuse. Findings include: -Resident #128 was admitted at the facility on December 4, 2023 with diagnoses that included dementia, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated on June 11, 2024 revealed the resident had a BIMS score of 4.0, which indicated severe cognitive impairment. Review of care plan initially dated on February 26, 2024 and revised on August 1, 2024 revealed that resident #128 use antidepressant medication. The interventions included to monitor/document/report to provider as needed ongoing signs and symptoms of depression which included fear of being alone with others, attention seeking, concern with body functions, anxiety, and constant reassurance. -Resident #66 (alleged…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-08 · 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 facility policy, the facility failed to ensure that necessary pain medications were given according to provider instruction for one resident (resident's #18) This deficient practice could result in ineffective medication management resulting in negative outcomes. findings include: -Resident #18 was admitted on [DATE], with diagnoses that included surgical aftercare, surgery on the circulatory system, end stage renal disease, and sepsis. A physician's order dated October 3, 2024, revealed an order for Tramadol 50mg (milligrams) by mouth every 12 hours as needed for a pain scale of 6-10. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident had no cognitive impairment. A care plan intervention with the initiated date of October 16, 2024, revealed that Resident #18 is at risk for pain and utilizes opioid medications per physician orders. Review…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-08 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 reviews, interviews, and facility documents and policy, the facility failed to ensure one resident (#54), had call light accessibility. The deficient practice could result in residents not having the means to communicate with staff leading to negative outcomes. Findings include: -Resident #54 was admitted to the facility on [DATE], with diagnoses that included left sided paralysis, stroke, Type-2 Diabetes, repeated falls, and depression. The quarterly Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS also revealed that the resident experienced social isolation on rare occasion and is prescribed an antidepressant for mood support. A falls care plan initiated November 25, 2022 revealed resident #54 was at risk for falls related to deconditioning, with a noted intervention to assure the bed is against the wall, and the call light is within reach to ensure…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#15) and (#50) were free from physical abuse resulting in injury by other residents (resident #50, and resident #75). The deficient practice could result in further incidents of resident to resident abuse. Findings include: Regarding resident #15 and resident #50 -Resident #15 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia, sepsis, urinary tract infections, dysphagia, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment September 8, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. A behavioral care plan revised December 6, 2023 revealed the resident was at risk of impaired cognitive function related to dementia with a noted intervention of keeping the resident's routine consistent and try to provide consistent care givers…

    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 F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#30) and (#60) were free from physical abuse resulting in injury by other residents (resident #90). The deficient practice could result in further incidents of resident to resident abuse. Findings include: Regarding resident #90 and resident #30 -Resident #30 was admitted to the facility on [DATE], with diagnoses that include Gout, Alcohol dependence, chronic obstructive pulmonary disorder, and hypertension. A behavioral care plan revised December 6, 2023 revealed the resident was at risk of impaired cognitive function replaced to dementia with a noted intervention of keep resident's routine consistent to provide consistent caregivers in order to reduce confusion. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated the resident had significant cognitive…

    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 before2023-02-02 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, interviews, and facility policies, the facility failed to ensure that medications were administered as ordered by the physician for one resident (#175). The deficient practice could result in medications not being available to meet the resident needs. Findings include: Resident #175 was admitted on [DATE] diagnosis of essential hypertension, other chest pain, atherosclerotic heart disease of native coronary artery without angina pectoris, and presence of aortocoronary bypass graft. The resident's comprehensive care plan included an intervention to administer medication as ordered. The health status note dated January 16, 2023 included the resident was alert and oriented x 4. A physician order dated January 16, 2023 included for ranolazine (anti-anginal drug) ER (extended release) 500 mg (milligrams) give one tablet by mouth two times a day for atherosclerotic heart disease of native coronary artery without angina pectoris. An eMAR (electronic medication…

    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

“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

$15,210 in federal fines across 1 penalty.

  • $15,210 — penalty dated 2026-02-10

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 2 of 52.8-0.8 vs chain
Health inspection 1 of 52.2-1.2 vs chain
Staffing 4 of 52.3+1.7 vs chain
Quality measures 5 of 54.7+0.3 vs chain
The other 19 homes this chain runs (chain average 2.8★, 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, JASONIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2013
HEALTH GROUP MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2013
DEWITT, KAYLAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/04/2018
ESPINOSA, STEPHANIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/14/2024
FRAGOSO, LINDSAYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/10/2021
GUERRERO TUCKER, GAILIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2015
MUIR, MARKIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/15/2015
ROBERTSON, BRETTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2013
SAMUELIAN, SPENCERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2013
SITCHLER, JONATHANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/10/2020
WEST, CHRISTIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2013
HAVEN ARIZONA REAL ESTATE, LLCOrganizationADP OF THE SNFsince 02/01/2013
HAVEN REAL ESTATE PARTNERS, LLCOrganizationADP OF THE SNFsince 02/01/2013
HAVEN SAFFORD REAL ESTATE LLCOrganizationADP OF THE SNFsince 02/01/2013

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.

4 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.

$7.9M
Net patient revenuemost recent cost report
+3.1%
Operating marginrevenue minus expenses
$499K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 77%Medicare 5%Other / private 17%

About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $499K 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

$322per resident / day
operating cost
$9,796per month
≈ monthly operating cost
$333per 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 2026-09-01 — CMS provider number 035172. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-08-05, 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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