Inspection Reports for
Haven Health Flagstaff

The complaint investigation revealed potential diversion of controlled substances by Registered Nurse Staff #54 involving Residents #13 and #15. The investigation included review of medication administration records, narcotic logs, interviews, and audits. Staff #54 was terminated for dishonesty and drug diversion. The Director of Nursing and Administrator confirmed discrepancies and reported the issue to law enforcement and state agencies.

The facility failed to ensure medications were not diverted for two residents, with discrepancies found between Medication Administration Records and narcotic sign-out sheets. Staff #54 was implicated in potential drug diversion, leading to termination for dishonesty and drug diversion.

The complaint investigation revealed potential diversion of narcotics by Registered Nurse Staff #54 involving Residents #13 and #15. The investigation included review of medication administration records, narcotic logs, interviews with staff and administration, and background checks. Staff #54 was terminated for dishonesty and drug diversion after discrepancies were confirmed.

The facility failed to ensure medications were not diverted for two residents, with discrepancies found between medication administration records and narcotic sign-out sheets. A staff member was identified as potentially diverting controlled substances, leading to termination for dishonesty and drug diversion.

The investigation was complaint-driven, focusing on incidents where Resident #10 was injured during transfers on March 20, 2025, and April 12, 2025. The complaints were substantiated as the resident sustained serious injuries including fractures. Staff interviews and family statements confirmed the incidents and inadequate transfer practices.

The facility failed to ensure Resident #10 was free from preventable accidents resulting in serious injury, including a right ankle injury on March 20, 2025, and a left leg fracture on April 12, 2025, both occurring during transfers. Staff training on safe transfers was inadequate, and proper transfer protocols were not consistently followed, leading to actual harm.

The investigation was complaint-related, focusing on incidents where Resident #10 was injured during transfers on March 20, 2025, and April 12, 2025. The resident sustained a right ankle injury and later tibia and fibula fractures. Family and staff interviews revealed concerns about staff rushing and inadequate transfer assistance. The complaint was substantiated with findings of actual harm.

The facility failed to ensure Resident #10 was free from preventable accidents during transfers, resulting in serious injuries including a stress fracture and tibia and fibula fractures. Staff training and care planning were inadequate, and proper transfer protocols were not consistently followed.

Life Safety Code recertification survey for Medicare under LSC 2012, Chapter 19. Facility meets standards based on acceptance of plan of correction. Two deficiencies cited related to corridor doors and smoke barrier construction.

Recertification survey combined with complaint investigations citing 6 deficiencies related to policies, abuse reporting, resident care, medication services, and food service contracts.

The complaint involved allegations that a resident was allowed to self-administer medication without proper assessment or physician order, a resident was abused by another resident, the facility failed to report the abuse to law enforcement, food was improperly labeled and stored, and medical records were incomplete and inaccurate. The facility investigation unsubstantiated the abuse allegation but failed to notify law enforcement. Interviews with staff confirmed these issues.

The facility failed to ensure safe self-administration of medication for one resident, failed to protect a resident from abuse by another resident, failed to report abuse allegations to law enforcement, failed to label and date food items properly, and failed to maintain complete and accurate medical records for two residents. The deficiencies posed minimal harm or potential for actual harm to a few residents.

The complaint involved an allegation that Resident #183 struck Resident #284. The facility investigated and unsubstantiated the allegation but failed to notify law enforcement. The Executive Director acknowledged the failure to notify law enforcement and could not explain why. The facility notified the state agency, ombudsman, family, and provider but not law enforcement.

The facility failed to ensure Resident #284 was free from abuse by Resident #183 and failed to implement their abuse policy properly, including failure to notify law enforcement of the abuse allegation. Additionally, the facility failed to maintain complete and accurate medical records reflecting the incident and related behaviors.

The complaint involved medication self-administration safety concerns for Resident #136, resident-to-resident abuse allegations between Residents #183 and #284, failure to report abuse to law enforcement, improper food labeling and storage, and incomplete medical record documentation. The facility investigation unsubstantiated the abuse allegation but failed to notify law enforcement. The complaint was substantiated with findings of deficient practices in all areas.

The facility failed to ensure safe medication self-administration for a resident, failed to prevent and properly report resident-to-resident abuse, failed to label and date food items properly, and failed to maintain complete and accurate medical records for residents. The facility also did not notify law enforcement regarding an abuse allegation and lacked documentation of the abuse incident in clinical records.

The complaint investigation involved an allegation that Resident #183 physically abused Resident #284 by hitting her. The facility's investigation found the allegation unsubstantiated but failed to report the abuse to law enforcement. Interviews with staff and the Executive Director confirmed the failure to notify law enforcement despite notifying other agencies. The facility also failed to document the incident properly in the clinical records.

The facility failed to protect residents from abuse by another resident and failed to implement their abuse policy properly, including not reporting the abuse allegation to law enforcement. Additionally, the facility failed to maintain complete and accurate medical records reflecting the abuse incident and related behaviors.

Complaint survey citing 3 deficiencies related to abuse reporting, resident abuse prevention, and care planning for pressure ulcers.

The complaint investigation focused on an incident on January 28, 2021, involving physical abuse between residents #1 and #2. The facility failed to report the incident to the state survey agency and failed to submit a timely 5-day investigation summary. Several staff involved in the incident were no longer employed at the facility at the time of the investigation.

The facility failed to ensure residents #1 and #2 were free from physical abuse, as an altercation occurred where resident #2 hit resident #1 and resident #1 hit back in self-defense. The facility also failed to submit a required 5-day written investigation summary to the state survey agency. Additionally, the facility failed to ensure consistent weekly wound care assessments for resident #3, which could lead to worsening pressure ulcers.

The complaint investigation focused on a physical altercation between two residents on January 28, 2021, which was not properly reported to the state survey agency. The facility also failed to submit a timely 5-day investigation summary. Several staff who witnessed the incident were no longer employed. The investigation included interviews with multiple staff and review of facility policies.

The facility failed to ensure two residents were free from physical abuse and did not submit a timely 5-day written investigation summary regarding the altercation. Additionally, the facility failed to ensure consistent weekly wound care assessments for one resident, potentially risking worsening pressure ulcers.

Complaint survey citing 4 deficiencies related to abuse investigations and resident abuse prevention.

The complaint investigation focused on an incident where resident #46 physically abused resident #71. The facility did not conduct a thorough investigation nor report the incident to the State Agency within the required 5 working days. Interviews with staff and the Executive Director confirmed the lack of a timely investigation and reporting.

The facility failed to ensure resident #71 was free from abuse by resident #46, who exhibited aggressive and threatening behaviors including slapping and swatting. Additionally, the facility failed to provide evidence of a thorough investigation and timely reporting of the abuse allegation to the State Agency within 5 working days.

The complaint investigation was substantiated by clinical record review, staff interviews, and facility policy review. The facility did not complete a timely investigation or report the abuse allegation involving residents #46 and #71 as required.

The facility failed to ensure resident #71 was free from abuse by resident #46 and failed to thoroughly investigate and report the abuse allegation to the State Agency within 5 working days. Documentation showed multiple incidents of resident #46 being aggressive and physically abusive toward resident #71 and staff, but no evidence of a completed investigation was found.

Life Safety Code recertification survey citing 4 deficiencies related to emergency preparedness exercises, corridor doors, fire drills, and emergency generator testing.

The complaint investigation included allegations of improper medication self-administration, failure to report abuse timely, incomplete PASRR referrals, unqualified activities program management, and failure to provide ordered rehabilitation services. The abuse allegation was not substantiated after investigation.

The facility was found deficient in multiple areas including failure to assess a resident for self-administration of medications, failure to timely report and investigate alleged abuse, failure to complete required PASRR Level II referrals and updates, lack of qualified professional directing the activities program, and failure to provide ordered rehabilitation services to a resident.

State compliance survey combined with complaint investigations citing 11 deficiencies related to abuse reporting, medication self-administration, PASRR coordination, activities program qualifications, rehabilitative services, and medication policies.

The complaint involved an allegation of abuse by a CNA toward Resident #13. The resident's daughter filed a grievance form and reported the incident to staff, but the facility failed to report and investigate the abuse within the required 2-hour window. The allegation was ultimately not substantiated by the surveyor's investigation.

The facility failed to timely report and investigate the alleged abuse within the required timeframe, resulting in the allegation not being investigated. Additionally, the activities program was found to be directed by an unqualified professional lacking required certification.

The facility was found deficient in multiple areas including failure to assess a resident for medication self-administration, failure to timely report and investigate an alleged abuse incident, failure to complete required PASRR Level II referral and update Level I screening for residents, lack of qualified professional directing the activities program, and failure to provide ordered rehabilitation services to a resident.

The complaint involved an alleged abuse incident where a CNA was reported to have been rough with Resident #13. The resident's daughter filed a grievance form and followed up multiple times but received no timely updates. The facility did not report the abuse allegation within the required 2-hour window. The surveyor reported the allegation during the survey, and the facility completed a self-report within 2 hours. The allegation was ultimately not substantiated.

The facility failed to report an alleged abuse incident involving Resident #13 within the required timeframe, resulting in the allegation not being investigated. Additionally, the facility's grievance process was found to be deficient as the submitted grievance form was not found, and the abuse allegation was not substantiated by the surveyor's investigation.

The complaint investigation substantiated that the facility failed to timely report an allegation of resident-to-resident abuse, failed to transmit a discharge MDS assessment timely, had inaccuracies in MDS assessments, did not provide activities according to resident preferences, and had sanitation and maintenance deficiencies in the kitchen.

The facility failed to timely report an allegation of resident-to-resident abuse, failed to transmit a discharge MDS assessment within the required timeframe, had inaccuracies in a resident's MDS discharge assessment, did not provide activities according to one resident's preferences due to unresolved TV issues, and had sanitation deficiencies in the kitchen including dishwasher chemical levels, unclean kitchenware, and dusty electrical cords above the tray line.

The complaint investigation involved an allegation of resident-to-resident abuse occurring on June 25, 2022, which was reported late to the State Agency on June 27, 2022. The nurse involved misunderstood the reporting process and only entered the incident into the risk management system without notifying the Director of Nursing or other required parties immediately. The Director of Nursing educated staff on timely reporting requirements following the incident.

The facility failed to timely report an allegation of resident-to-resident abuse, failed to transmit a discharge MDS assessment within the required timeframe, had inaccurate resident discharge assessments, did not provide activities according to a resident's preferences due to unresolved TV issues, and failed to maintain proper dishwasher sanitation and kitchen cleanliness.