Inspection Reports for Haven Health Flagstaff
800 W University Ave, Flagstaff, AZ 86001, United States, AZ, 86001
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Inspection Report
Complaint Investigation
Capacity: 83
Deficiencies: 24
Mar 14, 2025
Visit Reason
State-compiled facility profile showing 12 inspections from 2023-08 to 2025-03 with deficiency history and complaint investigations.
Findings
Across multiple inspections, the facility was found to have numerous deficiencies including failure to timely investigate and report abuse allegations, incomplete wound care assessments, inadequate PASRR screenings, unqualified activity management, failure to provide ordered rehabilitation services, and life safety code violations related to doors and emergency preparedness.
Complaint Details
Multiple complaint investigations were conducted including allegations of resident-to-resident abuse, failure to timely investigate and report abuse, and concerns about care and services. Several complaints were substantiated with deficiencies cited, while others had no deficiencies.
Deficiencies (24)
| Description |
|---|
| R9-10-403.C.2.b. Policies and procedures for physical health services and behavioral health services are established, documented, and implemented to protect the health and safety of a resident that cover the provision of physical health services and behavioral health services. |
| R9-10-403.E.1. An administrator shall report alleged or suspected abuse, neglect, or exploitation of the resident as required by law. |
| R9-10-410.B.3.a. A resident is not subjected to abuse. |
| R9-10-411.A.1. A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1. |
| R9-10-421.A.1.d. Procedures for documenting medication services and assistance in the self-administration of medication. |
| R9-10-423.A.3.b. The nursing care institution is able to store, refrigerate, and reheat food to meet the dietary needs of a resident. |
| Corridor - Doors: Doors protecting corridor openings resist passage of smoke and have positive latching hardware as required by NFPA 101 and CMS regulations. |
| Subdivision of Building Spaces - Smoke Barrier Construction: Smoke barriers constructed to 1/2-hour fire resistance rating per NFPA 101 and related codes. |
| R9-10-403.F.5.b. Initiate an investigation of suspected abuse and document injury and condition changes within five working days. |
| R9-10-403.F.2.a. Report suspected abuse, neglect, or exploitation within required timeframes. |
| R9-10-414.B.3.b. Care plan ensures resident is provided nursing care services to maintain highest practicable well-being. |
| §483.12 Freedom from Abuse, Neglect, and Exploitation: Facility must ensure residents are free from abuse including verbal, mental, sexual, or physical abuse. |
| §483.12(c)(2)(3)(4) Facility must thoroughly investigate allegations of abuse, prevent further abuse during investigation, and report results within 5 working days. |
| R9-10-403.C.2.a. Policies and procedures cover resident screening, admission, transport, transfer, discharge planning, and discharge. |
| §483.20(e) Coordination: Facility must coordinate assessments with PASRR program to avoid duplicative testing and effort. |
| §483.20(k) Preadmission Screening for individuals with mental disorder and intellectual disability: Facility must comply with screening and referral requirements. |
| §483.24(c)(2) Activities program must be directed by a qualified professional meeting state licensure or certification requirements. |
| R9-10-406.I.2. Administrator shall designate a qualified individual to provide recreational activities. |
| §483.65 Specialized rehabilitative services: Facility must provide or obtain required rehabilitative services as ordered by physician. |
| R9-10-413.B.6.f. Medical director shall ensure physical therapy services are provided or assisted in obtaining if not provided by facility. |
| (2) Testing: Facility must conduct annual emergency plan exercises including full-scale and tabletop exercises. |
| Corridor - Doors: Facility failed to maintain several doors properly, including gaps and failure to latch, risking smoke and heat passage. |
| Fire Drills: Facility failed to provide documentation of required quarterly fire drills on each shift for 2022-2023. |
| Electrical Systems - Essential Electric System Maintenance and Testing: Facility failed to document monthly 30-minute under load testing of emergency generator for multiple months. |
Report Facts
Inspections on page: 12
Total deficiencies: 30
Complaint inspections: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #28 | Director of Nursing | Named in abuse investigation findings and interview statements |
| Staff #42 | Executive Director | Named in abuse investigation findings and email correspondence |
| Staff #115 | Licensed Practical Nurse | Interviewed regarding abuse incident response |
| Staff #22 | Licensed Practical Nurse | Named in abuse incident notification and interview |
| Staff #95 | Activity Manager | Named in deficiency for unqualified activities program direction |
| Staff #58 | Administrator | Named in interviews regarding abuse reporting and grievance handling |
| Staff #8 | Resident Relations / RN | Named in interviews regarding PASRR and grievance handling |
| Staff #23 | Director of Nursing / RN | Named in interviews regarding medication self-administration and PASRR |
| Staff #3 | Certified Nursing Assistant | Interviewed regarding abuse recognition and response |
| Staff #101 | Physical Therapist | Interviewed regarding rehabilitation services |
| Staff #102 | Physical Therapy Assistant | Interviewed regarding rehabilitation services |
| Staff #75 | Certified Nursing Assistant | Interviewed regarding resident care and therapy |
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