Douglas, AZ

Haven Of Douglas

5-star overall rating with 3-star inspections with 10 recent health deficiencies

1400 North San Antonio Avenue, Douglas, AZ

(480) 935-4300

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

60

Certified beds

Average residents

50

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Haven Health

Operator or chain grouping

Approved since

1988-11-11

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

0.76

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

0.62

Licensed practical nurse staffing · state 1.04 · national 0.87

Aide hours / resident day

2.46

Nurse aide staffing · state 2.36 · national 2.35

Total nurse hours

3.84

All reported nurse hours · state 4.12 · national 3.89

Licensed hours

1.38

RN + LPN hours · state 1.76 · national 1.54

Weekend hours

3.29

Weekend nurse staffing · state 3.62 · national 3.43

Weekend RN hours

0.37

Weekend registered nurse coverage · state 0.51 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.84

CMS adjusted RN staffing hours

Adjusted total hours

4.29

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

14%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

30%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,405

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

56.88

Composite VBP score used to determine payment impact.

Payment multiplier

1.0120

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

10

Baseline 17.86% · Performance 20.83% · Measure score 10 · Achievement 10 · Improvement 0

Adjusted total nurse staffing

1.38

Baseline 3.53 hours · Performance 3.47 hours · Measure score 1.38 · Achievement 1.38 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.67%	10.72% 1.1 pts better	No Different than the National Rate · Eligible stays 26 · Observed rate 0% · Lower 95% interval 6.17%
Discharge to community	52.71%	50.57% 2.1 pts better	No Different than the National Rate · Eligible stays 28 · Observed rate 50% · Lower 95% interval 36.3%
Medicare spending per beneficiary	0.84	1.02 0.2 pts better
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	11.76%	8.2% 3.6 pts better	Numerator 10 · Denominator 85
Staff flu vaccination coverage	54.84%	42% 12.8 pts better	Numerator 68 · Denominator 124
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.6%	97.1% 0.5 pts better	93.4% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 97.8% · Q3 100.0% · Q4 97.6% · 4Q avg 97.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.8%	94.6% 0.8 pts worse	95.5% 1.7 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8%
Percentage of long-stay residents experiencing one or more falls with major injury	1.2%	2.1% 0.9 pts better	3.3% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.6%	4.2% 3.6 pts better	11.4% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6%
Percentage of long-stay residents who lose too much weight	0.6%	5.3% 4.7 pts better	5.4% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.1%	20.5% 1.4 pts better	19.6% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 20.5% · Q3 15.0% · Q4 20.0% · 4Q avg 19.1%
Percentage of long-stay residents who received an antipsychotic medication	0.0%	11.8% 11.8 pts better	16.7% 16.7 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 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	13.8%	14.5% 0.7 pts better	16.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 13.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.2%	10.8% 4.6 pts better	14.9% 8.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 4.7% · Q3 5.0% · Q4 7.5% · 4Q avg 6.2% · 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	0.6%	1.2% 0.6 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.3%	20.5% 3.8 pts worse	19.8% 4.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 34.2% · Q3 27.2% · Q4 23.3% · 4Q avg 24.3%
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 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.3% · 4Q avg 1.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	82.3%	91.1% 8.8 pts worse	81.7% 0.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 83.0% · Q2 84.2% · Q3 83.6% · Q4 78.3% · 4Q avg 82.3%
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	77.4%	87.3% 9.9 pts worse	79.7% 2.3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 77.4%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-07 · Fire 2025-08-07

10 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-07-25 · Fire 2024-07-25

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2023-01-26 · Fire 2023-01-26

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-07-25

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 2024-08-30

E · Potential for more than minimal harm 2024-07-25

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-09-04

E · Potential for more than minimal harm 2024-07-25

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-09-04

E · Potential for more than minimal harm 2023-01-26

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-03-20

E · Potential for more than minimal harm 2023-01-26

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-03-20

E · Potential for more than minimal harm 2023-01-26

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-03-20

E · Potential for more than minimal harm 2023-01-26

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2023-03-20

D · Potential for more than minimal harm 2023-01-26

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-03-20

D · Potential for more than minimal harm 2023-01-26

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-03-20

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-20

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 2025-12-20

D · Potential for more than minimal harm 2025-08-28

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 2025-09-25

E · Potential for more than minimal harm 2025-08-07

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 2025-10-01

E · Potential for more than minimal harm 2025-08-07

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-08-07

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-08-07

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-09-30

D · Potential for more than minimal harm 2025-08-07

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-08-07

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-08-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-10-01

D · Potential for more than minimal harm 2025-08-07

F825 · Quality of Life and Care Deficiencies

Health

Provide or get specialized rehabilitative services as required for a resident.

Corrected 2025-10-01

D · Potential for more than minimal harm 2024-07-25

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-07-25

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-08-30

D · Potential for more than minimal harm 2023-01-26

F560 · Resident Rights Deficiencies

Health

Protect a residents' right to refuse some types of non-requested transfers within the nursing home.

Corrected 2023-03-20

D · Potential for more than minimal harm 2023-01-26

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-03-20

D · Potential for more than minimal harm 2023-01-26

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2023-03-20

Penalties and ownership

What sits behind the stars

Ownership

Haven Health Group LLC

5% Or Greater Direct Ownership Interest · Organization

100% 19 facilities 2013-02-01

Samuelian, Stephen

5% Or Greater Indirect Ownership Interest · Individual

37% 20 facilities 2013-02-01

Samuelian, Spencer

5% Or Greater Indirect Ownership Interest · Individual

25% 31 facilities 2013-02-01

Samuelian, Robert

5% Or Greater Indirect Ownership Interest · Individual

20% 20 facilities 2013-02-01

Robertson, Brett

5% Or Greater Indirect Ownership Interest · Individual

8% 31 facilities 2013-02-01

West, Christian

5% Or Greater Indirect Ownership Interest · Individual

6% 31 facilities 2013-02-01

Brake, Adam