Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Of Flagstaff during CMS and state inspections, most recent first.
Two residents did not receive proper pharmaceutical services when controlled substances were diverted by a nurse, as evidenced by discrepancies between the MAR and narcotic logs, altered documentation, and medications being signed out after discontinuation. Staff interviews and record reviews confirmed that the required documentation and reconciliation were not maintained, resulting in drug diversion.
A resident with severe cognitive impairment and mobility deficits suffered two preventable injuries during transfers, including a right ankle fracture and left leg fractures, due to failure to update the care plan, lack of appropriate transfer assistance, and inadequate removal of wheelchair footrests. Staff did not implement two-person or mechanical lift transfers despite the resident's high risk and family requests.
Two residents with cognitive impairments were involved in a physical altercation in a facility, which was not reported to the state survey agency as required. Staff intervened to separate the residents and assessed them for injuries, but failed to document and report the incident according to facility policy.
A facility failed to submit a 5-day investigation report following an altercation between two residents, both with significant health issues. Staff intervened to separate the residents and assessed them for injuries, but there was no documented evidence that the incident was reported to the state survey agency. Interviews revealed that while protocols exist, the required report could not be located, indicating a lapse in documentation and reporting procedures.
A facility failed to provide consistent pressure ulcer care for a resident with multiple health issues, including unstageable pressure ulcers on both heels. Despite a care plan requiring weekly wound assessments, the facility's records showed gaps in documentation, with assessments not completed weekly as required. Staff interviews confirmed the expectation of weekly assessments, but these were not consistently performed, potentially worsening the resident's condition. The facility's policy mandated weekly risk assessments, but documentation did not consistently reflect this practice.
Failure to Prevent Diversion of Controlled Substances
Penalty
Summary
The facility failed to ensure that medications, specifically controlled substances, were not diverted for two residents. For one resident with diagnoses including hyperlipidemia, GERD, and heart failure, there were discrepancies between the Medication Administration Record (MAR) and the Individual Control Drug Record for Hydrocodone-Acetaminophen. The MAR showed limited administration of the medication, while the control record indicated it was signed out multiple times, including after the medication had been discontinued. This discrepancy was identified through review of records and staff interviews, revealing that the medication was signed out five times after discontinuation and not reflected on the MAR. For another resident with cellulitis, sepsis, and type 2 diabetes, similar inconsistencies were found. The MAR indicated that Oxycodone was administered only three times, but the control drug record showed it was signed out seventeen times. There were visible signs of alteration on the narcotic sheet, including overwritten entries and inconsistent documentation patterns. Staff interviews and an internal audit confirmed that the narcotic logs and MAR did not correspond, and the control drug record appeared tampered with. The investigation identified a registered nurse as the staff member responsible for the discrepancies. The nurse had signed off on medication administration that was not documented in the MAR and was found to have a history of a misdemeanor and an active warrant. The facility's process for counting and documenting controlled substances was described by staff, but the records showed that the required documentation and reconciliation between the MAR and narcotic sheets were not maintained, leading to the diversion of controlled substances.
Failure to Prevent Accidents During Resident Transfers
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, difficulty walking, severe cognitive impairment, and osteoporosis experienced two preventable injuries during transfers. The first incident took place in a common bathroom, where the resident's right ankle was injured during a transfer, resulting in swelling, pain, and a possible stress fracture. The investigation revealed that the footrests of the wheelchair were not removed during the transfer, and the resident's foot became caught, causing the injury. At the time, there was no evidence of a care plan addressing transfer needs for the resident. Following the first incident, there was no update to the resident's care plan to address transfer safety, and the resident did not receive a therapy referral. Staff were verbally reminded about safe transfer practices, but documentation shows that the care plan was not revised until several weeks later. Despite the resident's high risk for injury and the family's request for two-person assistance during transfers, these interventions were not implemented prior to the second incident. A second incident occurred when a CNA attempted a one-person transfer of the resident from a wheelchair to a bed. During this transfer, the resident's left leg became caught, resulting in a pop sound and severe pain. The resident was subsequently found to have sustained tibia and fibula fractures, requiring hospital treatment and surgery. Interviews with staff and the resident's family indicated that the transfer was performed too quickly, the resident's requests to slow down were not heeded, and language barriers may have contributed to communication difficulties during the transfer.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in an altercation between them. Resident #1, who was admitted with severe cognitive impairment and multiple health issues, was involved in a physical altercation with Resident #2, who also had significant health conditions including dementia and a history of falls. The incident occurred when a physical therapy assistant was maneuvering Resident #2 around a dining table, and Resident #2 began hitting Resident #1. Resident #1 retaliated in self-defense, and staff intervened to separate them. Both residents were assessed for injuries, and none were found. Despite the intervention and assessment, there was no documented evidence that the incident was reported to the state survey agency, as required. Interviews with staff revealed that while they were aware of the procedures for handling abuse, including separating residents and notifying relevant parties, the necessary documentation and reporting to the state agency were not completed. The facility's policy on abuse, which states that abuse is not condoned, was not adhered to in this instance, leading to a deficiency in ensuring resident safety and compliance with reporting requirements.
Failure to Submit 5-Day Investigation Report for Resident Altercation
Penalty
Summary
The facility failed to submit a 5-day written investigation summary regarding a physical altercation between two residents, which could result in allegations of abuse not being investigated. Resident #1, who was admitted with severe cognitive impairment and multiple health issues, was involved in an altercation with Resident #2, who also had significant health conditions including dementia. The incident occurred when Resident #2 began hitting Resident #1, leading to a physical exchange between the two. Staff intervened to separate the residents and assessed them for injuries, finding none. Notifications were made to family members and case managers, but there was no documented evidence that the incident was reported to the state survey agency. Interviews with staff revealed that while there is a protocol for handling such incidents, including immediate separation of residents and notification of relevant parties, the facility was unable to locate the required 5-day investigation report. The Director of Nursing acknowledged the requirement for timely reporting and investigation but could not confirm the completion of the report. The Executive Director later confirmed via email that the report could not be found, indicating a lapse in the facility's documentation and reporting procedures as per their policy.
Inconsistent Pressure Ulcer Care and Assessment
Penalty
Summary
The facility failed to ensure that a resident received care for pressure ulcers consistent with professional standards, as wound care assessments were not completed on a weekly basis. The resident, who was admitted with diagnoses including venous insufficiency, unstageable pressure ulcers on both heels, acute posthemorrhagic anemia, and cellulitis, had a care plan that required weekly wound assessments. However, the electronic health record showed gaps greater than seven days between assessments on multiple occasions. Interviews with staff confirmed that weekly assessments were expected but not consistently performed, which could lead to a worsening of the resident's condition. The facility's policy required weekly risk assessments for pressure injuries, but documentation did not consistently reflect this practice. Despite having a performance improvement plan in place since 2022 to address pressure ulcer and wound management, the facility did not maintain consistent weekly assessments for the resident in question. This deficiency was noted as past non-compliance, indicating that the facility had previously failed to adhere to its own policies and procedures regarding pressure ulcer care.
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Illustrative
What surveyors actually found near you
We read the 2 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Flagstaff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Transitional Care | 2 mi | ★★★★★ | 2 | 0 |
| The Peaks Health & Rehabilitation | 3.5 mi | ★★★★★ | 0 | 0 |
| Haven Of Sedona | 28.4 mi | ★★★★★ | 20 | 0 |
| Haven Of Cottonwood | 37.3 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.