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.

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 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.

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 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.

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 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.