Inspection Reports for
Haven Health Sky Harbor

The complaint involved Resident #100 alleging emotional abuse by a CNA who held a dirty brief close to the resident's face. The allegation was reported by a physical therapy assistant within 2 hours of hearing it. The facility conducted a 5-day investigation, suspended the CNA pending investigation, and reported the allegation to mandated entities. The investigation concluded the allegation was unable to be substantiated and no psychosocial harm was found.

The facility failed to timely report the alleged abuse within 2 hours as required, but the allegation was investigated thoroughly. The alleged perpetrator was suspended pending investigation, 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 for seven residents, which prevented thorough investigations and posed a risk to resident care.

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 involved allegations of abuse for two residents (#1 and #2). Resident #1 reported being abused by a male nurse who entered without knocking, shook her, and forced medication into her mouth while she was incapacitated. Resident #2 reported a nurse stuck her finger inappropriately during a shower and another nurse poured medicine in her mouth. The facility was notified by Adult Protective Services (APS) of an anonymous report. The allegations were investigated but could not be substantiated due to lack of identified perpetrators. The facility reported the complaint to APS, police, and Department of Health Services (DHS).

The facility failed to implement abuse prevention policies, timely report allegations of abuse to state agencies, and investigate allegations promptly. Two residents reported abuse incidents involving staff, but the facility was unable to substantiate the allegations due to lack of identified perpetrators. The facility implemented some interventions such as care in pairs for Resident #1 after the incident.

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.

The facility failed to maintain accurate documentation related to the deaths of two residents, including missing vital signs and incomplete records of the events surrounding their deaths. The facility was unable to locate documentation for one resident's death in both electronic and paper records.

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.

The complaint involved an allegation that a CNA popped resident #22 in the buttocks during incontinence care. The investigation from October 7 to October 11, 2024, determined the allegation was unsubstantiated. However, the care plan was not updated to reflect the resident's preference for female caregivers as stated in the investigation notes.

The facility failed to update the care plan for resident #22 to reflect the resident's preference for two female caregivers for incontinence care, despite the investigation determining the allegation was unsubstantiated. The care plan was not revised accordingly, and the Director of Nursing confirmed the care plan was not updated as required.

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.

The complaint was substantiated that the resident was transferred to the hospital without proper notification to the hospital or family, and the facility failed to provide adequate discharge documentation and communication to the receiving hospital. The resident was taking up a bed in the ICU for ventilation management, and the hospital was unaware of the transfer until notified by the ambulance en route.

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 no notification to the resident's family. Multiple attempts to find appropriate placement for the resident were unsuccessful, and the resident self-initiated the transfer. The facility did not follow its own policies regarding transfer notifications and documentation.

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.

The complaint investigation focused on resident #48's communication deficits and the facility's failure to provide appropriate ASL-tactile interpretation services, resulting in isolation and unmet needs. Additional complaints included inadequate meal assistance, lack of activities, staffing documentation issues, improper medication administration, dental care deficiencies, food safety concerns, and incomplete clinical documentation. The investigation included interviews with family, staff, and service providers, as well as review of policies and records.

The facility failed to develop and implement a complete care plan addressing resident #48's communication needs, including the use of ASL-tactile interpreters. Staff lacked training in tactile sign language, resulting in poor communication and care. The facility also failed to provide timely meal assistance, maintain adequate staffing records, ensure proper medication administration, provide dental care, maintain food safety standards, and accurately document resident care. The quality assurance program did not adequately address these issues.

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.

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 inconsistent adherence to protocols for notifying providers and documenting medication delays. The complaint was substantiated with findings of minimal harm or potential for harm.

The facility failed to ensure that medications (Atorvastatin, Gabapentin, Methocarbamol) were administered as ordered for resident #400, resulting in potential missed doses due to delays in pharmacy delivery and medication availability. Interviews with nursing staff and pharmacy personnel revealed procedural gaps in medication administration and documentation.

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, leading to an emergency situation where residents were transported to hospitals. The oxygen supply system was not properly monitored, and there was no log prior to the incident to track oxygen tank levels. The facility has since implemented a log and emergency preparedness training.

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 with findings that resident #1 was sexually abused on April 22, 2023 by the spouse of another resident. Multiple staff interviews confirmed the incident and inadequate monitoring. The resident reported the abuse and medical examination confirmed minor genital injuries.

The facility failed to protect resident #1 from sexual abuse by a visitor who was the spouse of another resident. The investigation revealed multiple staff and resident interviews, observations of inadequate visitor monitoring, non-functioning video cameras, and lack of visitor sign-out procedures. The facility acknowledged deficiencies in visitor control and monitoring.

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 visit was complaint-related, triggered by allegations of failure to maintain resident dignity, medication errors, infection control deficiencies, inadequate care, and lack of staff training. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to maintain resident dignity, medication administration errors, improper infection control practices, failure to provide timely continence care, inadequate respiratory care, lack of monitoring psychotropic medication side effects, and insufficient staff training on resident rights, abuse prevention, dementia care, and infection control.

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 untimely Minimum Data Set (MDS) assessments, incomplete baseline and comprehensive care plans, medication administration errors, inadequate pressure ulcer care, 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.

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.