Cycle 1
Health 2025-01-24 · Fire 2025-01-24
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Phoenix, AZ
Haven Of Phoenix
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4202 North 20th Avenue, Phoenix, AZ
(602) 264-3824
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Haven Health
Operator or chain grouping
Approved since
1985-06-24
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.17
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
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.14
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,031
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.8
Baseline 20.88% · Performance 21.06% · Measure score 0.8 · Achievement 0.8 · Improvement 0
Healthcare-associated infections
4.54
Baseline 5.97% · Performance 6.48% · Measure score 4.54 · Achievement 4.54 · Improvement 0
Total nurse turnover
4.64
Baseline 50.55% · Performance 44.71% · Measure score 4.64 · Achievement 4.64 · Improvement 1.77
Adjusted total nurse staffing
0
Baseline 3.43 hours · Performance 3.09 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.38% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 12.23% · Lower 95% interval 8.43% |
| Discharge to community | 56.02% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 49.62% · Lower 95% interval 47.9% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 57 · Denominator 57 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 57 |
| Discharge self-care score | 61.11% |
53.69%
7.4 pts better
|
Numerator 22 · Denominator 36 |
| Discharge mobility score | 52.78% |
50.94%
1.8 pts better
|
Numerator 19 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 57 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.48% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 5.63% · Lower 95% interval 4.06% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 131 |
| Staff flu vaccination coverage | 23.48% |
42%
18.5 pts worse
|
Numerator 31 · Denominator 132 |
| Discharge function score | 61.11% |
56.45%
4.7 pts better
|
Numerator 22 · Denominator 36 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.7% |
25.2%
16.5 pts worse
|
Numerator 2 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
97.1%
2.1 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 98.3% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
94.6%
2.7 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
2.1%
1 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
4.2%
2.6 pts worse
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 5.2% · Q3 14.3% · Q4 5.9% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
5.3%
2.8 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 3.2% · Q4 5.7% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
20.5%
1.3 pts worse
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 21.9% · Q3 20.3% · Q4 18.9% · 4Q avg 21.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.9% |
11.8%
9.9 pts better
|
16.7%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 2.3% · Q4 0.0% · 4Q avg 1.9% · 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 | 7.7% |
14.5%
6.8 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
10.8%
6.5 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 6.6% · Q4 3.8% · 4Q avg 4.3% · 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 | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 with new or worsened bowel or bladder incontinence | 20.1% |
20.5%
0.4 pts better
|
19.8%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 25.3% · Q3 22.8% · Q4 13.1% · 4Q avg 20.1% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.8%
2.6 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.4% · Q3 1.1% · Q4 1.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
91.1%
6.4 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 97.6% · Q3 97.4% · Q4 99.1% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
10.7%
6.2 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 19.2% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.1%
1 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.4% |
87.3%
6.1 pts better
|
79.7%
13.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.0% |
24.6%
7.4 pts worse
|
23.9%
8.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.0% · Observed 34.6% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-08 · Fire 2023-09-08
8 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-07-28 · Fire 2022-07-28
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-29
E · Potential for more than minimal harm
2023-09-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-09-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-09-08
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 2023-11-16
D · Potential for more than minimal harm
2023-09-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-09-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-16
D · Potential for more than minimal harm
2022-07-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-09-12
D · Potential for more than minimal harm
2022-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-12
Inspection history
Recent health citations
G · Actual harm
2025-12-16
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 2026-02-26
E · Potential for more than minimal harm
2025-01-24
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-24
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 2025-02-21
D · Potential for more than minimal harm
2025-01-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-21
D · Potential for more than minimal harm
2024-09-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-20
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 2024-10-01
E · Potential for more than minimal harm
2023-09-08
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 2023-11-17
D · Potential for more than minimal harm
2023-09-08
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 2023-11-17
D · Potential for more than minimal harm
2023-09-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-09-08
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-09-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-17
E · Potential for more than minimal harm
2022-07-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-28
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-28
Penalties and ownership
What sits behind the stars
Ownership
Ahmed, Bahaledin
Operational/Managerial Control · Individual
Espinosa, Stephanie
Operational/Managerial Control · Individual
Fragoso, Lindsay
Operational/Managerial Control · Individual
Gandhi, Hemang
Operational/Managerial Control · Individual
Greiner, Russell
Operational/Managerial Control · Individual
Haven Health Group LLC
5% Or Greater Direct Ownership Interest · Organization
Haven Health Properties LLC
5% Or Greater Mortgage Interest · Organization
Haven Phoenix Real Estate LLC
5% Or Greater Mortgage Interest · Organization
Health Group Management LLC
Operational/Managerial Control · Organization
Ivancich, Casey
Operational/Managerial Control · Individual
Robertson, Brett
5% Or Greater Direct Ownership Interest · Individual
Samuelian, Robert
5% Or Greater Direct Ownership Interest · Individual
Samuelian, Spencer
5% Or Greater Direct Ownership Interest · Individual
Samuelian, Stephen
5% Or Greater Direct Ownership Interest · Individual
Seastrand, Jason
Operational/Managerial Control · Individual
West, Christian
5% Or Greater Direct Ownership Interest · Individual
West, Christian
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
The Rehabilitation Center At The Palazzo
Phoenix, AZ
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Beatitudes Campus
Phoenix, AZ
3-star overall rating with 2-star inspections with 6 recent health deficiencies
#3
Camelback Post Acute Care And Rehabilitation
Phoenix, AZ
4-star overall rating with 3-star inspections with 9 recent health deficiencies
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