17 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (9 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lakeside, AZ
1-star overall rating with 1-star inspections with abuse icon flag with $8,278 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3401 North Lockwood Drive, Lakeside, AZ
(928) 368-2060
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
112
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Haven Health
Operator or chain grouping
Approved since
2010-11-02
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
RN hours / resident day
0.62
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.32
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
13,008
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.82
Baseline 22.76% · Performance 22.00% · Measure score 0.82 · Achievement 0 · Improvement 0.82
Healthcare-associated infections
0
Baseline 9.15% · Performance 9.70% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.80
Baseline 60.76% · Performance 52.24% · Measure score 2.80 · Achievement 2.80 · Improvement 1.87
Adjusted total nurse staffing
0
Baseline 3.49 hours · Performance 2.80 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.13% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 239 · Observed rate 10.88% · Lower 95% interval 8.17% |
| Discharge to community | 50.59% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 220 · Observed rate 47.73% · Lower 95% interval 43.72% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 167 · Denominator 167 |
| Falls with major injury | 1.2% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 167 |
| Discharge self-care score | 52.5% |
53.69%
1.2 pts worse
|
Numerator 42 · Denominator 80 |
| Discharge mobility score | 53.75% |
50.94%
2.8 pts better
|
Numerator 43 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 1.23% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 163 · Adjusted rate 1.25% |
| Healthcare-associated infections requiring hospitalization | 9.7% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 141 · Observed rate 10.64% · Lower 95% interval 5.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 120 |
| Staff flu vaccination coverage | 30.65% |
42%
11.4 pts worse
|
Numerator 38 · Denominator 124 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 48 · Denominator 80 |
| Transfer of health information to provider | 90.48% |
95.95%
5.5 pts worse
|
Numerator 57 · Denominator 63 |
| Transfer of health information to patient | 87.84% |
96.28%
8.4 pts worse
|
Numerator 65 · Denominator 74 |
| Resident COVID-19 vaccinations up to date | 39.33% |
25.2%
14.1 pts better
|
Numerator 35 · Denominator 89 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.5
1.1 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.9% |
97.1%
12.2 pts worse
|
93.4%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.3% · Q2 86.2% · Q3 86.4% · Q4 76.5% · 4Q avg 84.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 79.5% |
94.6%
15.1 pts worse
|
95.5%
16 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 79.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
2.1%
2 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 3.1% · Q3 3.0% · Q4 1.5% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
4.2%
0.3 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 5.0% · Q3 0.0% · Q4 0.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 9.6% |
5.3%
4.3 pts worse
|
5.4%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 9.3% · Q3 7.1% · Q4 6.6% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
20.5%
8.4 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 7.4% · Q3 10.3% · Q4 21.3% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
11.8%
2.2 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 10.0% · Q3 7.5% · Q4 11.6% · 4Q avg 9.6% · 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 | 6.6% |
14.5%
7.9 pts better
|
16.3%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 13.4% · Q3 4.1% · Q4 3.9% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.7% |
10.8%
7.1 pts better
|
14.9%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.9% · Q3 1.9% · Q4 7.0% · 4Q avg 3.7% · 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 | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.2% |
20.5%
3.3 pts better
|
19.8%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 9.4% · Q3 29.4% · Q4 19.4% · 4Q avg 17.2% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
4.8%
2.3 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 7.4% · Q3 4.4% · Q4 5.8% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.5% |
91.1%
8.6 pts worse
|
81.7%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.4% · Q2 78.2% · Q3 81.0% · Q4 83.9% · 4Q avg 82.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
10.7%
4.7 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 15.9% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.1%
0.4 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.8% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.3% |
87.3%
22 pts worse
|
79.7%
14.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
24.6%
3.4 pts better
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 20.5% · Expected 23.0% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (9 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-30
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-25
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-08-16
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2021-08-16
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2021-08-16
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-08-16
Inspection history
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Not marked corrected
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Not marked corrected
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
Health
Respond appropriately to all alleged violations.
Not marked corrected
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-08
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-10
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-04
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-04
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-28
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-28
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-12
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-08-16
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-08-16
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-16
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-02-24
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 2023-02-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-24
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-24
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 2023-02-24
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 2023-02-24
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-02-24
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-02-24
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-02-24
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-24
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-02-24
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-02-24
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-02-24
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-02-24
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-08-19
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2021-08-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-08-19
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-08-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-08-19
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-19
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 2021-08-19
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-08-19
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-08-19
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 2021-08-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-19
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-08-19
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-08-19
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 2021-08-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-19
Penalties and ownership
Fine · fine $8,278
Fine
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Mortgage Interest · Organization
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
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