Deficiency Index

Haven of Flagstaff

Flagstaff, Arizona · CCN 035091

16 surveys since 2010. The first finding at harm level was recorded in 2025.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
70
Surveys
16
Harm or worse
1
Immediate jeopardy
0
The record, 2010–2025
’10’15’20’25
No harm recordedHarm or worseNot surveyed
Harm or worse1

Findings where a surveyor recorded actual harm to a resident.

Beyond CMS’s monthly file9/16

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
83
Ownership
For profit - Corporation
Chain
HAVEN HEALTH
County
Coconino
Medicare-certified since
1984

CMS ratings

Overall
3
Health inspection
2
Staffing
3
Quality measures
5

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded somewhat more weighted findings than its peer group.

Weighted by harm level, against 15 for-profit facilities of 66–99 beds in Arizona.

Last survey on record

Dec 22, 2025

322 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day3.354.22
Registered-nurse hours per resident day0.83—
Annual nurse turnover43.8%45.1%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

Fines
$13,098 across 1 penalty
Abuse icon
Flagged by CMS on Care Compare

Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG14.2%H—I—
No harm, potential for more than minimalD2187.5%E28.3%F—
No harm, potential for minimalA—B—C—
CMS’s current file: 24 of the 70 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F6094×

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

  • F6003×

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • F5542×

    Allow residents to self-administer drugs if determined clinically appropriate.

  • F8122×

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • F6071×

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

In the surveyor’s words

From the most serious findings on record at Haven of Flagstaff, in the surveyor’s own words.

  • Actual harm, isolatedF689Apr 29, 2025

    Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident (#10) was free from a preventable accident that resulted in serious injury. The deficient practice could lead to further instances of accidents resulting in injuries to residents. Findings include: Resident #10 was admitted on [DATE], with diagnoses that included acute kidney failure, cardiac murmur, repeated falls, difficulty in walking, and age-related osteoporosis. […]

  • No harm, potential for more than minimal, patternF680Oct 5, 2023

    Based on personnel record review, staff interview, and the job description, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in not providing activities that meet the physical and psychosocial needs of the residents. Findings include: Review of the personnel file for the Activity Manager (staff #95) revealed staff #95 was hired on July 30, 2021 as a CNA (Certified Nursing Assistant) and promoted to the Activity Manager on June 10, 2023. […]

  • No harm, potential for more than minimal, patternF812Aug 18, 2022

    Based on observations, staff interviews, manufacturer manual, and policy reviews, the facility failed to ensure the dishwasher sanitation was monitored, kitchenware was clean and dry, and that the electrical cord and outlets above the tray line were clean. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding dishwasher sanitation During the initial kitchen observation conducted on August 15, 2022 at 10:03 a.m., a staff member was observed testing the chemical dishwasher machine. The test indicated that the sanitizer level was low. It should be between 50-100 parts per million (ppm). The dishwasher (staff #97) adjusted the bucket tubing and tested the chemicals twice before it yielded the appropriate result. […]

  • No harm, potential for more than minimal, isolatedF755Dec 22, 2025

    Based on observations, interviews, clinical record reviews, facility documentation, and facility policies, the facility failed to ensure that medications were not diverted for two residents (#13 and #15). This deficient practice could result in Controlled Substance being diverted and not being available to residents as prescribed.Findings Include: -Regarding Resident #15:Resident #15 was admitted to the facility on [DATE], with diagnoses of hyperlipidemia, Gastro-Esophageal Reflux Disease (GERD), and heart failure.A care plan initiated on November 13, 2025, revealed a focus area for the Resident #15 to be on Opiate medications related to post-surgical. […]

  • No harm, potential for more than minimal, isolatedF554Mar 14, 2025

    Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one of five sampled resident (#136) were safe to self-administer medication. The deficient practice could result in a medication overdose. Findings Include: Resident #136 was admitted on [DATE] with diagnosis of dysphasia, chronic obstructive pulmonary disease, bipolar disorder, depression, anxiety and pressure ulcer. The Admission Assessment Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. […]

Read 20 findings in full →The most serious and the most recent: 20 of 70 on record.

Every survey on record

FindingsAt actual harm or above

  • Dec 22, 2025Complaint1 finding
  • Apr 29, 2025Complaint1 finding · 1 harm
  • Mar 14, 2025Standard and complaint6 findings
  • Oct 23, 2024Complaint3 findings
  • Dec 14, 2023Complaint2 findings
  • Oct 5, 2023Standard and complaint6 findings
  • Aug 18, 2022Standard and complaint5 findings
  • Oct 26, 2020Standard7 findings
Show the 8 earlier surveys
  • Jun 2, 2020Infection control1 finding
  • Jan 24, 2019Standard and complaint4 findings
  • Oct 20, 2016Standard1 finding
  • Jul 23, 2015Standard10 findings
  • May 22, 2014Standard5 findings
  • Mar 7, 2013—7 findings
  • Dec 8, 2011—3 findings
  • Oct 8, 2010—8 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction