Cycle 1
Health 2025-03-14 · Fire 2025-03-14
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Flagstaff, AZ
Haven Of Flagstaff
3-star overall rating with 2-star inspections with abuse icon flag with $13,098 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
800 West University Avenue, Flagstaff, AZ
(928) 779-6931
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
83
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Haven Health
Operator or chain grouping
Approved since
1984-02-08
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
0.81
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,733
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.06
Baseline 21.91% · Performance 18.71% · Measure score 6.06 · Achievement 5.88 · Improvement 6.06
Healthcare-associated infections
1.74
Baseline 7.12% · Performance 7.32% · Measure score 1.74 · Achievement 1.74 · Improvement 0
Total nurse turnover
1.52
Baseline 51.39% · Performance 57.45% · Measure score 1.52 · Achievement 1.52 · Improvement 0
Adjusted total nurse staffing
1.01
Baseline 3.57 hours · Performance 3.36 hours · Measure score 1.01 · Achievement 1.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.55% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 298 · Observed rate 9.06% · Lower 95% interval 8.09% |
| Discharge to community | 56.73% |
50.57%
6.2 pts better
|
No Different than the National Rate · Eligible stays 301 · Observed rate 53.49% · Lower 95% interval 50.34% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 191 · Denominator 191 |
| Falls with major injury | 0.52% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 191 |
| Discharge self-care score | 72.31% |
53.69%
18.6 pts better
|
Numerator 94 · Denominator 130 |
| Discharge mobility score | 66.92% |
50.94%
16 pts better
|
Numerator 87 · Denominator 130 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 191 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.32% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 190 · Observed rate 6.84% · Lower 95% interval 5% |
| Staff COVID-19 vaccination coverage | 5.17% |
8.2%
3 pts worse
|
Numerator 6 · Denominator 116 |
| Staff flu vaccination coverage | 21.01% |
42%
21 pts worse
|
Numerator 25 · Denominator 119 |
| Discharge function score | 70% |
56.45%
13.5 pts better
|
Numerator 91 · Denominator 130 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | 98.43% |
96.28%
2.2 pts better
|
Numerator 125 · Denominator 127 |
| Resident COVID-19 vaccinations up to date | 23.76% |
25.2%
1.4 pts worse
|
Numerator 24 · Denominator 101 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
97.1%
1.3 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 100.0% · Q3 97.9% · Q4 97.8% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.6%
5.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
2.1%
0.5 pts worse
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.9% · Q3 2.1% · Q4 2.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
4.2%
1.2 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 12.1% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.3%
3.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.9% · Q4 2.6% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.1% |
20.5%
11.4 pts better
|
19.6%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 14.0% · Q3 11.1% · Q4 10.3% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
11.8%
8 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.2% · Q3 4.3% · Q4 0.0% · 4Q avg 3.8% · 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 | 15.5% |
14.5%
1 pts worse
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
10.8%
5.8 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.3% · Q3 8.3% · Q4 5.1% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 1.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.3% |
20.5%
9.8 pts worse
|
19.8%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 30.3% · Q3 24.0% · Q4 33.8% · 4Q avg 30.3% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.8%
2.1 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.8% · Q3 2.5% · Q4 2.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
91.1%
4.2 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 95.3% · Q3 97.3% · Q4 96.6% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
10.7%
3 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 7.7% · Expected 11.1% · 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 | 96.1% |
87.3%
8.8 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
24.6%
3.2 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 20.8% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-22
E · Potential for more than minimal harm
2025-03-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-22
E · Potential for more than minimal harm
2023-10-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-06
D · Potential for more than minimal harm
2022-08-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-22
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 2026-01-20
G · Actual harm
2025-04-29
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 2025-05-30
D · Potential for more than minimal harm
2025-03-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-14
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 2025-04-09
D · Potential for more than minimal harm
2025-03-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-09
D · Potential for more than minimal harm
2025-03-14
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 2025-04-09
D · Potential for more than minimal harm
2025-03-14
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 2025-04-09
D · Potential for more than minimal harm
2025-03-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-09
D · Potential for more than minimal harm
2024-10-23
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 2024-12-09
D · Potential for more than minimal harm
2024-10-23
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 2024-12-09
D · Potential for more than minimal harm
2024-10-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-03-01
D · Potential for more than minimal harm
2023-12-14
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 2024-01-03
D · Potential for more than minimal harm
2023-12-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-10-05
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-05
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 2023-11-06
D · Potential for more than minimal harm
2023-10-05
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 2023-11-06
D · Potential for more than minimal harm
2023-10-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-10-05
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-11-06
E · Potential for more than minimal harm
2022-08-18
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 2022-09-15
D · Potential for more than minimal harm
2022-08-18
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 2022-09-15
D · Potential for more than minimal harm
2022-08-18
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-09-15
D · Potential for more than minimal harm
2022-08-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-15
D · Potential for more than minimal harm
2022-08-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-09-15
Penalties and ownership
What sits behind the stars
$13,098
2025-03-14
Fine
Fine · fine $13,098
Fine
Ownership
Espinosa, Stephanie
Operational/Managerial Control · Individual
Figueroa-Diaz, Vicente
Operational/Managerial Control · Individual
Fragoso, Lindsay
Operational/Managerial Control · Individual
Haven Arizona Real Estate, LLC
5% Or Greater Mortgage Interest · Organization
Haven Flagstaff Real Estate LLC
5% Or Greater Mortgage Interest · Organization
Haven Health Group LLC
5% Or Greater Direct Ownership Interest · Organization
Haven Real Estate Partners, LLC
5% Or Greater Mortgage Interest · Organization
Health Group Management LLC
Operational/Managerial Control · Organization
Longhurst, Stock
Operational/Managerial Control · Individual
Mccullough, Erin
Operational/Managerial Control · Individual
Miller, Crystal
Operational/Managerial Control · 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
Sciara, Patrick
Operational/Managerial Control · Individual
Seastrand, Jason
Operational/Managerial Control · Individual
Smith, Wendy
Operational/Managerial Control · Individual
Ternion Physician Group, Pllc
Operational/Managerial Control · Organization
West, Christian
5% Or Greater Direct Ownership Interest · Individual
West, Christian
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Aspire Transitional Care
Flagstaff, AZ
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 24 fire-safety deficiencies in the latest cycle
#2
The Peaks Health & Rehabilitation
Flagstaff, AZ
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Haven Of Sedona
Sedona, AZ
2-star overall rating with 1-star inspections with abuse icon flag with 24 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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