Inspection Reports for
Haven Health Sky Harbor

The complaint involved an allegation by Resident #100 that a CNA held a dirty brief close to her face, causing emotional abuse. The allegation was reported late to mandated entities, contrary to facility policy requiring reporting within 2 hours. The investigation included interviews with staff and the resident, review of time punch reports, and facility policies. The alleged perpetrator was suspended pending investigation. The allegation was ultimately unsubstantiated, and no psychosocial harm was found.

The facility failed to report the allegation of abuse to mandated entities within 2 hours as required. The investigation found that the alleged perpetrator CNA was suspended, and post-incident monitoring showed no psychosocial harm to the resident. The allegation was ultimately unable to be substantiated. Additionally, the facility failed to maintain complete medical records necessary to investigate cases of seven residents, which posed a potential risk to resident care.

The complaint investigation involved two residents (#1 and #2) with allegations of abuse including forced medication administration, inappropriate touching, and sexual abuse. The facility was notified by Adult Protective Services (APS) of an anonymous report. The investigation included interviews with staff and residents, review of progress notes, and facility policies. No staff member was identified as the alleged perpetrator, and the allegations were unsubstantiated. The facility reported the complaint to APS, police, and Department of Health Services (DHS).

The facility failed to implement abuse prevention policies, timely report suspected abuse to proper authorities, and investigate allegations of abuse in a timely manner for two residents. The investigation found no staff member identified as the alleged perpetrator and the abuse allegations were unsubstantiated. Interventions were implemented to prevent further harm.

Investigation of intake # SF00123180

A complaint survey was conducted for intake # SF00123180 with one deficiency cited related to medical record maintenance.

The facility failed to maintain accurate documentation surrounding the deaths of two residents, including missing vital signs and incomplete records of the circumstances of death. The facility was unable to locate documentation for Resident #6's death in both electronic and paper records.

Investigation of complaint #'s AZ00217107, AZ00217522, AZ00217188

Complaint survey conducted for complaint #'s AZ00217107, AZ00217522, AZ00217188 with two deficiencies cited related to comprehensive care plans and care plan review.

The complaint alleged that a CNA popped resident #22 in the buttocks during incontinence care. The allegation was investigated and found unsubstantiated. The care plan was not updated as required to reflect the resident's preference for female caregivers.

The investigation determined the allegation was unsubstantiated; however, the facility failed to update the resident's care plan to reflect the requested preference for two female caregivers for incontinence care, which was only noted as an alert in the electronic medical record.

Investigation of intake #s AZ00213882 and AZ00213931

Complaint survey conducted for intake #s AZ00213882 and AZ00213931 with two deficiencies cited related to transfer and discharge requirements and transfer documentation.

The complaint investigation revealed that resident #1 was transferred to an out-of-state hospital without prior notification to the hospital or the resident's family. The hospital was unaware of the transfer until the ambulance notified them en route. The resident's family was not informed of the transfer until after it occurred. The facility failed to provide a discharge summary or report to the receiving hospital. The transfer was initiated by the resident's request, but the facility did not follow proper procedures for safe discharge and communication.

The facility failed to provide adequate documentation and communication during the transfer of resident #1 to an out-of-state hospital, including lack of physician orders for discharge, no report given to the receiving facility, and failure to notify the resident's family prior to transfer. Multiple attempts to find appropriate placement for the resident were unsuccessful, and the transfer was resident-driven. The facility did not follow its own policies regarding transfer notification and documentation.

Investigation of intake #s AZ00203480 and AZ00199182

State compliance survey conducted in conjunction with complaint investigations with 20 deficiencies cited related to quality management, care plans, staff training, resident care, staffing, medication, food safety, and documentation.

The facility failed to adequately address the communication needs of a resident (#48) who is deaf and blind and uses ASL-tactile, resulting in lack of appropriate interpreter services and staff training. There were deficiencies in providing assistance with meals, ensuring food was served warm and palatable, maintaining sanitary kitchen conditions, and ensuring accurate clinical documentation. Staffing records were incomplete, and the facility failed to ensure a registered nurse worked 8 consecutive hours daily. Pain medication administration outside ordered parameters was identified and addressed through QAPI. Dental care was not consistently provided or scheduled. Activities were insufficiently documented and did not meet resident needs.

Recertification survey for Medicare under Life Safety Code 2012, Chapter 18, New. Facility meets standards based on acceptance of plan of correction with one deficiency related to electrical equipment testing and maintenance.

Investigation of intake #s AZ00208350, AZ00206490, AZ00203611 and AZ00203650

Complaint survey conducted for intake #s AZ00208350, AZ00206490, AZ00203611 and AZ00203650 with two deficiencies cited related to medication administration compliance.

The complaint investigation found that medications for resident #400 were delayed due to pharmacy delivery timing and lack of availability in the facility's e-kits and pyxis machine. Staff interviews indicated gaps in notifying providers and documenting medication delays or refusals. The facility policy requires timely medication administration and documentation, which was not consistently followed.

The facility failed to administer prescribed medications to resident #400 as ordered, resulting in missed doses due to delays in pharmacy delivery and medication availability. Interviews with staff revealed inconsistent processes and documentation regarding medication administration and communication with providers.

The facility failed to ensure adequate oxygen supply for six residents, resulting in an emergent situation where residents were transported to hospitals. Oxygen supply monitoring was inadequate prior to the incident, and there was no log tracking oxygen tank usage before 1/2/2024. The facility has since implemented a log and emergency preparedness training.

The complaint investigation was substantiated. Resident #1 reported sexual abuse by a visitor (spouse of another resident) on April 22, 2023. The visitor was found in the resident's room with pants down. The resident reported the visitor raped her. The facility investigation and medical examination confirmed minor genital injuries consistent with the assault.

The facility failed to protect resident #1 from sexual abuse by a visitor who was the spouse of another resident. The investigation revealed the visitor was found on top of resident #1 in her room, and the resident reported being raped. Multiple staff interviews and medical examinations confirmed the incident. The facility lacked adequate visitor monitoring and had non-functioning video cameras.

The facility was found deficient in multiple areas including failure to maintain resident dignity related to catheter privacy, medication administration errors, improper respiratory care, failure to provide timely continence care, inadequate monitoring of psychotropic medications, lack of infection preventionist training, and incomplete staff training on resident rights, abuse prevention, and infection control.

The facility was found deficient in multiple areas including incomplete and overdue MDS assessments, failure to develop baseline and comprehensive care plans addressing psychotropic medications, splinting devices, and IV antibiotic use, medication administration errors, inadequate pressure ulcer care and documentation, failure to provide routine dental care, failure to notify residents and families of COVID-19 positive staff, and failure to ensure residents received scheduled showers and vision care assistance.