Living Waters Hospice, LLC
A hospice in Golden Valley, Arizona 86413
3711 West Highway 68, Golden Valley, Arizona 86413. (928) 565-9000.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 10 deficiencies cited in the last three years
- 5of 5 family caregiver rating
- 7of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
10 deficiencies cited in the last three years
The middle of the 11 hospices serving ZIP code 86413 had 8.
The last inspection on record was on Dec 6, 2024: a reaccreditation inspection by The Joint Commission.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
10 deficiencies in 1 month of the last 36. Last cited Dec 2024. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Dec 6, 2024: reaccreditation inspection by The Joint Commission10 deficiencies
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Content of comprehensive assessment (42 CFR 418.54(c)(5))
“Observed in Record Review. In 1 of 19 patient records reviewed, the patient assessment did not include the patient’s needs for psychosocial and emotional care as required by policy. In the chart for RRNHV#9, the patient was assessed to have depression, multiple losses, disfigurement, history of substance abuse and pain management issues. There was no assessment of suicide risk as required by organizational policy Suicide risk assessment, intervention and care planning for patients exhibiting these issues. This was discussed with the DPCS.”
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Patient outcome measures (42 CFR 418.54(e)(2))
The inspectors’ words, 108 words
“Observed in Record Review. In 1 of 19 patient records reviewed, the patient record did not include information needed to justify the patient’s care, treatment or services. In the chart for RRHV#1, the patient had non-verbal signs of pain at the admission visit, so a Fentanyl patch was ordered. Pain was assessed to be none at every subsequent visit during the first benefit period and there was no documentation of education about pain management using a pain patch. The Fentanyl patch was discontinued at the time of the first recert assessment. The record was unclear if the patch had ever been applied. This was discussed with the DPCS.
”
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Content of plan of care (42 CFR 418.56(c)(4))
“Observed in Record Review. In 1 of 19 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness. In the chart for RRHV#3, the patient was documented upon assessment in the first two nursing visits to be using oxygen prn. There was no oxygen order on the plan of care. This was discussed with the DPCS.”
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Review of the plan of care (42 CFR 418.56(d))
“Observed in Record Review. In 1 of 19 patient records reviewed, plan of care revisions did not include progress toward goals and outcomes. In the chart for RRNHV#5, the Social Work documentation in each of the most recent five IDT meetings were the exact same verbiage with the exception of when the patient would be seen again and included no new information about progress toward goals. This was discussed with the DPCS.”
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Professional management responsibility (42 CFR 418.100(e)(1))
“Observed in Document Review. In 1 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that services may be provided only with the authorization of the hospice. This stipulation was missing in the pharmacy contract. This was discussed with the Administrator.
”
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Professional management responsibility (42 CFR 418.100(e)(3))
“Observed in Document Review. In 1 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that services are delivered in accordance with the plan of care. This stipulation was missing in the pharmacy contract. This was discussed with the Administrator.”
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Training (42 CFR 418.100(g)(3))
“Observed in HR File Review. In 1 of 8 HR files reviewed, staff had not participated in ongoing education and training. In the file for HR3, there was no documentation of any annual education about Infection Control and Blood Borne Pathogens as required by OSHA. This was verified with the Volunteer Coordinator.”
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Content (42 CFR 418.104(a)(7))
The inspectors’ words, 159 words
“Observed in Record Review. In 2 of 19 patient records reviewed, the patient record did not contain an accurate list of medications. During RRHV#4, it was observed that the list in the hospice EMR and in the patient home did not match what the patient was receiving. The EMR stated Metoprolol 25 mg daily. The caregiver indicated that for more than the past three months, she administers 1/2 of one tablet twice daily which matched the prescription bottle in the home. Additionally, the caregiver indicated that the Midodrine was discontinued more than three months prior to the survey, yet remained on the list in the home as well as in the EMR. This was observed by and discussed with the DPCS present at the visit. In the chart for RRNHV#12, the RN noted the patient had started taking Allegra for itching. This medication had not been added to the plan of care/medication list. This was discussed with the DPCS.”
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Discharge or transfer of care (42 CFR 418.104(e)(1)(i))
“Observed in Record Review. In 1 of 1 patient records with a transfer, when the patient was discharged to another Medicare facility, the hospice had not provided the receiving facility with a copy of the hospice discharge summary. There was no documentation in the record for RRDC#16 that the hospice provided any information to the hospital when the patient revoked the hospice benefit for treatment for a fracture. This was discussed with the DPCS.”
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Criminal background checks (42 CFR 418.114(d)(1))
“Observed in Document Review. In 2 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that the contracted entity obtains criminal background checks on contracted employees who have direct patient contact or access to patient records. This stipulation was missing in the pharmacy and DME contracts. This was discussed with the Administrator.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Dec 6, 2024 | Reaccreditation inspection by The Joint Commission | 10 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Nov 28, 2012.
- Ownership: other.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 7.2 nurse care minutes per routine home care day, 4.1% of skilled nursing minutes at weekends and a visit near death for 78% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 71% at home, 24% in assisted living, 4% in a skilled nursing facility.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 7.2 min |
| Skilled nursing minutes at weekends | 4.1% |
| Visits near death | 78.0% of patients who died |
Who owns it?
- Sbla Management, LLC owns 100% directly since Mar 14, 2023.
- 6 owners or officers are people: Blaine L Whitson (owns 5% or more through other companies, 100%); Blaine L Whitson (corporate officer, 100%); Blaine L Whitson (corporate director, 100%); Blaine L Whitson (managing employee (on the payroll), 100%); John A Weidner (managing employee (under contract), 0%); Rebecca Edwards (managing employee (on the payroll), 0%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Sbla Management, LLC | Owns 5% or more directly | 100% | Mar 14, 2023 |
What do families say?
- Family caregivers rate it 5 of 5 in CMS’s survey (Oct 1, 2023 to Sep 30, 2025): 88% rated it 9 or 10 out of 10, and 93% would definitely recommend it.
- CMS’s Hospice Care Index: 7 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 95.82% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 44.9% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | 5 of 5 |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 7 of 10 |
How does it compare nearby?
- Of the 11 hospices CMS’s data show serving patients in ZIP code 86413, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 8; this one had 10.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Living Waters Hospice, LLC This hospice | 10 |
| Kingman Regional Medical Center Hospice | Not given |
| Hospice Compassus - Bullhead City | 4 |
| Beacon of Hope Hospice | 11 |
| River Valley Hospice | 0 |
| Billet Hospice Inc. Bullhead City | 3 |
| Family Care Hospice | 32 |
| Arizona Life Hospice - Mohave | Not given |
| Serenity Hospice | 8 |
| Canyon Hospice | 0 |
| Comfort and Peace Hospice | 11 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.