Haven of Phoenix

Inspectors wroteBased on a review of records, observation, interviews, policies and procedures, the facility failed to ensure that two residents (#122 and #163) were not abused by another resident (#121 and #60) out of 11 sampled residents. The Universe was 99. The deficient practice could lead to physical and psychosocial harm to residents. Regarding the altercation between Resident #121 and Resident #122-Regarding #121, (Alleged Perpetrator) Resident #121 was re-admitted to the facility on [DATE], with diagnoses that included encephalopathy, anxiety, and bipolar disorder. A Physical Aggression incident report dated April 27, 2026, at 5:35 p.m., revealed that a Nurse was notified of an incident involving Resident #121 (alleged perpetrator) and #122 (alleged victim), who shared a room. [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that medications were administered as ordered for two of five sampled residents (Resident #32 and #56). The deficient practice could result in resident's pain not being controlled. Regarding Resident #32: Resident #32 was readmitted to the facility on [DATE], with a diagnosis that included schizoaffective disorder, bipolar type; bipolar disorder; major depressive disorder; and anxiety disorder. A care plan focus dated February 24, 2025, revealed Resident #32 had polyneuropathy pain. Interventions included that the staff were to anticipate his need for pain relief and respond as soon as possible. A physician's order dated October 8, 2025, revealed Resident #32 is to take one 325 mg tablet of oxycodone-acetaminophen every 5 hours as needed for pain levels of 6 to 10. [...]

Inspectors wroteBased on observation, review of the clinical records, staff interviews, review of the Blood Glucose Monitoring System User's Guide, and review of the facility's policy and procedure, the facility failed to ensure that staff conducted proper hand sanitizing during a meal service and infection control procedures were performed after a point of care testing for blood sugar check, for one resident (#164) to help prevent a transmission of infections according to acceptable clinical standards of practice. The census was 99. The deficient practice could result in the spread of infectious diseases to other residents and could place the residents at risk for infection.

Inspectors wroteBased on the review of the clinical records, staff interviews, and from the Arizona Health Care Cost Containment System, the Pre-admission Screening and Resident Review (PASRR), the facility failed to ensure the PASARR (pre-admission screening and resident review) was updated appropriately and accurately submitted, when applicable, for one resident (#32). The census was 99. The deficient practice could result in residents' medically related social and emotional needs not being met. The census was 99.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that pain management was provided to one resident (#137) consistent with professional standards of practice, and the resident's comprehensive person-centered care plan. The deficient practice could place the resident's health at risk by not adequately treating the resident's pain.

Inspectors wroteBased on observation, staff interviews, and policy documentation, the facility failed to ensure that the daily nurse staffing information posted included all data requirements. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for one (#56) of 29 sampled residents. The deficient practice could result in harm to the residents, and/or visitors who have access to medications.

Inspectors wroteBased on documentation, staff and resident interviews, and review of the facility policy and procedures, the facility failed to ensure the safety of one resident (#5) by not properly securing the resident and failing to maintain a safe speed during transport. The deficient practice could result in residents being physically injured.

Inspectors wroteBased on personnel file review, staff interviews, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. This deficient practice could have resulted in the activities provided not meeting the assessed needs of the residents. Findings Include: A review of the personnel file for the role of activity manager (AD/Staff #111) was conducted on May 21, 2024. However, the review did not reveal evidence that staff #111 possessed the qualifications required for the role of activities director. An interview was conducted on January 23, 2025, at 9:38 A.M. with staff #111, Activities Director. Staff #111 stated that she had been working at the facility as an Activities Director for several years. [...]

Inspectors wroteBased on clinical record review, facility documents, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#395) was free from neglect, by failing to ensure the resident was administered care and services to meet his needs. The deficient practice could result in residents not being provided the necessary services.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one of 21 sampled residents (#82) had a referral for a Level II PASRR (pre-admission screening and resident review). The deficient practice could result in the resident not receiving specialized services needed.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and process, the facility failed to ensure that care was provided according to professional standards and that the resident's basic needs are being met for one resident (#42). The deficient practice could result in residents not being provided the care needed to maintain or improve health. Resident #42 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis, cystitis, major depressive disorder, and multiple myeloma not having achieved remission. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating intact cognition. Section I revealed the resident had an active diagnosis of diabetes mellitus. [...]

Inspectors wroteBased on documentation, staff interviews, and the facility policy and process, the facility failed to ensure that care was provided according to professional standards and that the resident's basic needs are being met for one resident (#10). The deficient practice could result in residents not being provided the care needed to maintain or improve health.

Inspectors wroteBased on documentation, staff interviews and the facility policy and procedures, the facility failed to report an allegation of abuse to the state survey agency and failed to complete and submit a 5-day written investigation timely. The deficient practice could result in residents not being protected and being abused.

Inspectors wroteBased on record review, staff interviews, and the facility policy and procedures, the facility failed to ensure residents (#26, #25, and #3) were provided with the appropriate level of supervision. The deficient practice could result in the personal space of residents not being respected.

Inspectors wroteThe facility failed to ensure food was properly stored, prepared, handled and served according to professional standards. Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure resident do not sustain preventable accidents including falls resulting in major injury. Failure to ensure this resulted increased morbidity and mortality.

Inspectors wroteBased on observations, staff interviews, facility recipes, and policy review, the facility failed to ensure the nutritive value of puree food. The deficient practice could result in residents receiving food with altered nutritive value.

Inspectors wroteBased on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food brought by visitors and family was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value.

Inspectors wroteBased on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that infection control standards were maintained regarding hand hygiene and donning gloves by an LPN (Licensed Practical Nurse/staff #74) during medication administration. The deficient practice could result in the spread of infection to residents.