Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HAVEN OF SHOW LOW
SHOW LOW, AZ · 58 certified beds · Last Life Safety survey November 6, 2024
CMS Certification Number 035139 · first certified March 1987
Ownership
Operated by HAVEN HEALTH · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within AZ
18 citations — more than 85% of the 140 certified nursing homes in AZ. Compared within AZ rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 5.7. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (January 2026 to September 2026). Most AZ facilities have been surveyed by December 2026. This facility’s last Life Safety survey was November 2024. Facilities in AZ are typically surveyed 14–22 months after the last one (median 18), measured over 143 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 18 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 18 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in AZ, and nationally. Surveyors differ markedly between states, so the AZ figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 18 |
| Median facility in AZ | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 9, 2022 | 3 |
| August 10, 2023 | 3 |
| August 8, 2024 | 11 |
| November 6, 2024 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 2 | 2024-08-08 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-08-08 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2024-08-08 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2024-08-08 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2024-08-08 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 1 | 2024-08-08 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2022-06-09 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2024-08-08 |
What the citations cover
- Smoke Deficiencies 8
- Emergency Preparedness Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Egress Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Emergency Preparedness Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 6, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 3, 2024) |
August 8, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (August 16, 2024) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (September 20, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (September 20, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 20, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 20, 2024) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (September 20, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (September 20, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 19, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 19, 2024) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (September 16, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 20, 2024) |
August 10, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 15, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 15, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (October 15, 2023) |
June 9, 2022 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (July 5, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 5, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 5, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.