Cycle 1
Health 2024-05-23 · Fire 2024-05-23
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Green Valley, AZ
Haven Health Green Valley, LLC
3-star overall rating with 2-star inspections with abuse icon flag with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
150 North La Canada Drive, Green Valley, AZ
(520) 625-0178
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
111
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Haven Health
Operator or chain grouping
Approved since
1981-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing
LPN hours / resident day
0.84
Licensed practical nurse staffing
Aide hours / resident day
2.06
Nurse aide staffing
Weekend hours
2.91
Weekend nurse staffing
RN turnover
14%
Annual RN turnover
Total nurse turnover
18%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.1%
2.4 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.6%
3.7 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
2.1%
0.6 pts worse
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
4.2%
2.4 pts worse
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.3%
2.3 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
20.5%
About the same
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 2.8% |
11.8%
9 pts better
|
16.7%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.1% |
14.5%
14.6 pts worse
|
16.3%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
10.8%
1.2 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.2%
0.2 pts worse
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.5% |
20.5%
9 pts worse
|
19.8%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
4.8%
3.5 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
91.1%
5.8 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.9% |
10.7%
6.8 pts better
|
12.0%
8.1 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.1%
1.1 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
87.3%
2.4 pts better
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
24.6%
7.6 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-13 · Fire 2023-01-13
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-10-28 · Fire 2021-10-28
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-05-23
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-06-20
D · Potential for more than minimal harm
2023-01-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-01-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-01-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-01-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-01-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-24
E · Potential for more than minimal harm
2021-10-28
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-10-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-10-28
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-10-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-06
D · Potential for more than minimal harm
2021-10-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-05-23
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-06-15
E · Potential for more than minimal harm
2024-05-23
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-05-23
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-23
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-05-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-05-23
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-04-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-07
E · Potential for more than minimal harm
2023-01-13
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-01-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-01-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-01-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-01-13
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-01-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-01-13
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-01-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-01-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-01-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-01-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-01-13
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-01-13
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-01-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-13
E · Potential for more than minimal harm
2021-10-28
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-11-25
E · Potential for more than minimal harm
2021-10-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-11-25
E · Potential for more than minimal harm
2021-10-28
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2021-11-25
D · Potential for more than minimal harm
2021-10-28
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2021-11-25
D · Potential for more than minimal harm
2021-10-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-11-25
D · Potential for more than minimal harm
2021-10-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-11-25
D · Potential for more than minimal harm
2021-10-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-11-25
D · Potential for more than minimal harm
2021-10-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-11-25
D · Potential for more than minimal harm
2021-10-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-11-25
D · Potential for more than minimal harm
2021-10-28
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2021-11-25
Penalties and ownership
What sits behind the stars
Ownership
Eaglen, Robyn
Operational/Managerial Control · Individual
Eaglen, Robyn
W-2 Managing Employee · Individual
Espinosa, Stephanie
Operational/Managerial Control · Individual
Espinosa, Stephanie
Corporate Officer · Individual
Fragoso, Lindsay
Operational/Managerial Control · Individual
Fragoso, Lindsay
Corporate Officer · Individual
Hatch, Brandon
Operational/Managerial Control · Individual
Hatch, Brandon
W-2 Managing Employee · Individual
Haven Green Valley Real Estate LLC
5% Or Greater Mortgage Interest · Organization
Haven Health Group LLC
5% Or Greater Direct Ownership Interest · Organization
Haven Health Properties LLC
5% Or Greater Mortgage Interest · Organization
Health Group Management LLC
Operational/Managerial Control · Organization
Muir, Mark
Operational/Managerial Control · Individual
Muir, Mark
Contracted Managing Employee · Individual
Robertson, Brett
5% Or Greater Direct Ownership Interest · Individual
Robertson, Brett
Operational/Managerial Control · Individual
Samuelian, Robert
5% Or Greater Direct Ownership Interest · Individual
Samuelian, Robert
Operational/Managerial Control · Individual
Samuelian, Spencer
5% Or Greater Direct Ownership Interest · Individual
Samuelian, Spencer
Operational/Managerial Control · Individual
Samuelian, Stephen
5% Or Greater Direct Ownership Interest · Individual
Samuelian, Stephen
Operational/Managerial Control · Individual
Seastrand, Jason
Operational/Managerial Control · Individual
Seastrand, Jason
Contracted Managing Employee · Individual
Shah, Virag
Operational/Managerial Control · Individual
Shah, Virag
Contracted Managing Employee · Individual
West, Christian
5% Or Greater Direct Ownership Interest · Individual
West, Christian
Operational/Managerial Control · Individual
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