13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (8 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Safford, AZ
3-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1933 Peppertree Drive, Safford, AZ
(928) 428-4910
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
Beds
106
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Haven Health
Operator or chain grouping
Approved since
1988-04-28
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
RN hours / resident day
1.08
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.07
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.74
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
1.05
CMS adjusted RN staffing hours
Adjusted total hours
2.98
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
7,936
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.83
Baseline 20.01% · Performance 19.66% · Measure score 3.83 · Achievement 3.83 · Improvement 0.68
Healthcare-associated infections
4.67
Baseline 5.12% · Performance 6.44% · Measure score 4.67 · Achievement 4.67 · Improvement 0
Total nurse turnover
2.83
Baseline 62.90% · Performance 52.11% · Measure score 2.83 · Achievement 2.83 · Improvement 2.34
Adjusted total nurse staffing
0
Baseline 3.06 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 6.25% · Lower 95% interval 6.96% |
| Discharge to community | 65.31% |
50.57%
14.7 pts better
|
Better than the National Rate · Eligible stays 77 · Observed rate 70.13% · Lower 95% interval 56.39% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.51% |
95.27%
3.2 pts better
|
Numerator 66 · Denominator 67 |
| Falls with major injury | 2.99% |
0.77%
2.2 pts worse
|
Numerator 2 · Denominator 67 |
| Discharge self-care score | 70.73% |
53.69%
17 pts better
|
Numerator 29 · Denominator 41 |
| Discharge mobility score | 58.54% |
50.94%
7.6 pts better
|
Numerator 24 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 67 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.44% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 2.22% · Lower 95% interval 2.88% |
| Staff COVID-19 vaccination coverage | 1% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 100 |
| Staff flu vaccination coverage | 0.93% |
42%
41.1 pts worse
|
Numerator 1 · Denominator 107 |
| Discharge function score | 68.29% |
56.45%
11.8 pts better
|
Numerator 28 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 93.33% |
96.28%
3 pts worse
|
Numerator 42 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 7.89% |
25.2%
17.3 pts worse
|
Numerator 3 · Denominator 38 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 3.8% |
2.1%
1.7 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 6.8% · Q4 6.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
4.2%
3.5 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
5.3%
2.4 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 1.9% · Q3 8.9% · Q4 6.9% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.7% |
20.5%
0.8 pts better
|
19.6%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 22.6% · Q3 19.3% · Q4 15.3% · 4Q avg 19.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.1% |
11.8%
8.3 pts worse
|
16.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 19.0% · Q3 18.6% · Q4 18.6% · 4Q avg 20.1% · 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 | 9.9% |
14.5%
4.6 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
10.8%
5.5 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.1% · Q3 7.5% · Q4 8.8% · 4Q avg 5.3% · 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 | 18.7% |
20.5%
1.8 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 19.1% · Q3 19.2% · Q4 17.2% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.8%
2 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.8% · Q3 3.8% · Q4 1.8% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.1%
8.2 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.3% · Q3 99.2% · Q4 99.2% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
10.7%
3.3 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.4% · Expected 11.2% · 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 | 94.4% |
87.3%
7.1 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.2% |
24.6%
8.4 pts better
|
23.9%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 14.8% · Expected 21.8% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (8 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-24
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-04-24
Fire Safety
Install resident room doors of proper design and width.
Corrected 2023-04-24
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-09
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-03-09
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-09
Inspection history
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2026-02-11
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-11
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-11
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-02
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-02
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-02-02
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-20
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-20
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-20
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-20
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-20
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-20
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-25
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
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-03-11
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-03-11
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 2022-03-11
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-03-11
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 2022-03-11
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-03-11
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 2022-03-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-03-11
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 2022-03-11
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 2022-03-11
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-03-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-11
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-11
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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