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
Chain footprint
20 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,177
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.23
Composite VBP score used to determine payment impact.
Payment multiplier
1.0055
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.10
Baseline 20.31% · Performance 17.68% · Measure score 8.10 · Achievement 8.10 · Improvement 7.51
Healthcare-associated infections
1.24
Baseline 6.33% · Performance 7.46% · Measure score 1.24 · Achievement 1.24 · Improvement 0
Total nurse turnover
10
Baseline 28.57% · Performance 18.06% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.16
Baseline 4.15 hours · Performance 3.41 hours · Measure score 1.16 · Achievement 1.16 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.82% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 353 · Observed rate 8.78% · Lower 95% interval 8.42% |
| Discharge to community | 68.7% |
50.57%
18.1 pts better
|
Better than the National Rate · Eligible stays 349 · Observed rate 68.48% · Lower 95% interval 64.91% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.58% |
95.27%
4.3 pts better
|
Numerator 236 · Denominator 237 |
| Falls with major injury | 0.42% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 237 |
| Discharge self-care score | 47.69% |
53.69%
6 pts worse
|
Numerator 62 · Denominator 130 |
| Discharge mobility score | 45.38% |
50.94%
5.6 pts worse
|
Numerator 59 · Denominator 130 |
| Pressure ulcers or injuries, new or worsened | 0.84% |
2.29%
1.5 pts better
|
Numerator 2 · Denominator 237 · Adjusted rate 0.97% |
| Healthcare-associated infections requiring hospitalization | 7.46% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 209 · Observed rate 6.7% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 8.45% |
8.2%
0.2 pts better
|
Numerator 12 · Denominator 142 |
| Staff flu vaccination coverage | 34% |
42%
8 pts worse
|
Numerator 51 · Denominator 150 |
| Discharge function score | 46.15% |
56.45%
10.3 pts worse
|
Numerator 60 · Denominator 130 |
| Transfer of health information to provider | 74.4% |
95.95%
21.5 pts worse
|
Numerator 154 · Denominator 207 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.87% |
25.2%
2.7 pts better
|
Numerator 34 · Denominator 122 |
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 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 100.0% · 4Q avg 99.5% |
| 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 · 4Q avg 98.3% |
| 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 · Q1 0.0% · Q2 1.8% · Q3 1.9% · Q4 7.8% · 4Q avg 2.7% · Used in QM five-star |
| 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 · Q1 13.0% · Q2 5.6% · Q3 3.8% · Q4 3.9% · 4Q avg 6.6% |
| 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 · Q1 4.4% · Q2 6.8% · Q3 0.0% · Q4 0.0% · 4Q avg 3.0% |
| 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 · Q1 22.2% · Q2 18.2% · Q3 15.0% · Q4 27.0% · 4Q avg 20.5% |
| 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 · Q1 0.0% · Q2 3.7% · Q3 3.6% · Q4 4.0% · 4Q avg 2.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 40.3% · 4Q avg 29.1% · Used in QM five-star |
| 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 · Q1 11.9% · Q2 7.3% · Q3 10.5% · Q4 8.6% · 4Q avg 9.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 1.7% · Q2 1.8% · Q3 0.0% · Q4 2.0% · 4Q avg 1.4% · Used in QM five-star |
| 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 · Q1 40.7% · Q2 27.3% · Q3 22.0% · Q4 27.4% · 4Q avg 29.5% |
| 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 · Q1 1.6% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| 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 · Q1 98.2% · Q2 94.9% · Q3 96.5% · Q4 97.9% · 4Q avg 96.9% |
| 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 · Adjusted 3.9% · Observed 3.7% · Expected 10.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 89.7% |
| 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 · Adjusted 17.0% · Observed 16.3% · Expected 22.8% · Used in QM five-star |
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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