Inspection Reports for
Haven Health Flagstaff

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-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 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.

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.

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.

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

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 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.