Haven of Scottsdale

Inspectors wroteNumber of residents sampled: 46Number of residents cited: 1Based on observation, interview, review of clinical record, staff interviews, review of facility's video footage, policy and procedure, the facility failed to ensure adequate supervision was provided to one resident (#27). The deficient practice resulted in the resident sustaining injury from accidental foley catheter dislodgement and a transfer to the hospital.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement their policy on abuse reporting and investigation for allegations of abuse for 2 of 9 sampled residents (#77 and #72). The deficient practice could result in allegations of abuse not reported, not investigated and residents not protected from continued abuse.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure an allegations of abuse were reported to APS and law enforcement; and failed to ensure that the results of the investigations of the alleged violation for 2 of 9 sampled residents (#77 and #72) were submitted to the SA within 5 working days of the incident. The deficient practice could result in allegations of abuse not investigated and residents not protected from continued abuse.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure allegations of abuse for 2 of 9 sampled residents (#77 and #72) were thoroughly investigated. The deficient practice could result in residents not protected from continued abuse and appropriate corrective action not taken.

Inspectors wrote-Regarding Resident #82: Resident #82 was admitted on [DATE], with diagnoses that included end stage renal disease and type 2 diabetes mellitus. An admission Evaluation note dated January 2, 2026, revealed Resident #82 admitted from short-term general hospital for intravenous (IV) infusions with contact isolation. A physician order dated January 3, 2026, included contact isolation due to Extended-Spectrum Beta-Lactamases (ESBL) for 5 days or until treatment has been completed on January 6. A care plan focus dated January 4, 2026, revealed the resident had an active infection including ESBL with interventions that included contact/droplet isolation precautions, educate resident and staff regarding preventative measures to contain infection, use as much disposable equipment as possible or use dedicated equipment (i.e. [...]

Inspectors wroteBased on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a resident (#27) was treated with dignity and respect. The deficient practice could lead to psychosocial harm of a resident.-

Inspectors wroteBased on clinical record review, staff interviews and review of facility documentation and policy, the facility failed to ensure that the Ombudsman was provided a copy of the notice of discharge for 2 of 3 sampled residents (#76 and #70). The deficient practice could result in residents being inappropriately discharged .

Inspectors wroteBased on review of clinical record, interview, and review of facility policy and procedure, the facility failed to ensure a resident (#27) was administered narcotic medication according to physician order. The deficient practice could lead to physical harm of a resident from overdose of narcotic medication.-

Inspectors wroteBased on clinical record review, staff interviews and facility documentation and policy review, the facility failed to ensure care and services related to pressure ulcer was provided to 1 of 3 sampled residents (#64). The deficient practice could result in worsening of the resident's pressure ulcer.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure protocols for reconciliation of controlled medications were followed by staff to prevent diversion of narcotic medications for 2 sampled residents (#73 and #74). The deficient practice could result in result in risk of harm including inadequate relief of pain and complications associated with the medication use and misuse.

Inspectors wroteBased on observations, staff interviews and review of policies and procedures, the facility failed to ensure that food was labeled and stored in accordance with professional standards. The deficient practices could result in food-borne illnesses.

Inspectors wroteBased on review of clinical record, interviews, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for one resident (#27). The deficient practice could lead to care team members not being fully aware of a resident's status.-

Inspectors wroteBased on clinical record review, staff interviews and policy reviews, the facility failed to ensure that 1 of 3 sampled residents (#1) received the appropriate inhalation powder per physician orders. The deficient practice could result in uncontrolled symptoms related to chronic obstructive pulmonary disease (COPD).

Inspectors wroteBased on review of documentation, interviews with staff and residents and review of the facility policy, the facility failed to ensure two residents are free from verbal abuse (#5 and #30). The deficient practice could lead to psychosocial harm for residents.

Inspectors wroteBased on review of documentation, interviews and review of the facility policy, the facility failed to report alleged abuse for two residents (#5 and #30). The deficient practice could lead to continued abuse for residents.

Inspectors wroteBased on review of documentation, interviews and review of the facility policy, the facility failed to ensure 3 residents ( #456, #457 and #458) were not abused from one staff member. The deficient practice could lead residents to suffer from psychosocial harm.

Inspectors wroteBased on review of documentation, interviews and review of the facility policy, the facility failed to ensure the policy for abuse was implemented for 3 residents (#456, #457 and #458). The deficient practice could lead residents to suffer from psychosocial harm and further abuse of more residents from staff member.

Inspectors wroteBased on review of documentation, interviews and review of the facility policy, the facility failed to report alleged violations of abuse for resident's (#456, #457 and #458) . The deficient practice could lead to further abuse of residents from staff member.

Inspectors wroteBased on review of documentation, interviews and review of the facility policy, the facility failed to investigate and correct alleged violations of abuse for resident's (#456, #457 and #458) from one staff member (staff #42). The deficient practice could lead residents to suffer from psychosocial harm and further abuse of residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy reviews, the facility failed to ensure three of four sampled residents (#14, #4, #40) were administered scheduled pain medication in accordance with the physician order. The deficient practice could result in residents' pain not being adequately controlled. Findings Include: -Regarding Resident #14: Resident #14 was initially admitted on [DATE] with diagnoses that included COPD, displaced fracture of 5th cervical vertebra, major depressive disorder, and insomnia. A care plan initiated on July 16, 2021 revealed that the resident has chronic pain and takes an opioid and non-opioid analgesic related to chronic pain of the bilateral lower extremities. Interventions that were initiated on March 4, 2021, indicated to administer analgesia medication as per orders. Physician orders revealed the following: -Dated April 5, 2022: [...]

Inspectors wroteBased on personnel file review, staff interview, and facility policy review, the facility failed to ensure that three of three sampled Certified Nursing Assistants (CNA/ Staff#48, Staff#61, and Staff#42) maintained valid Cardiopulmonary Resuscitation (CPR) and first aid certifications. The deficient practice could result in potential harm to residents due to staff not being knowledgeable about how to provide emergency care to residents as part of the CPR team.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure one resident (#96) was free from misappropriation of the resident's property. The deficient practice could result in resident rights being violated due to the misappropriation of personal property. Findings Include: Resident #96 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, anxiety disorder and cellulitis. Resident #96's inventory sheet dated December 7, 2022 revealed that the resident had 1 phone and 1 charger in her possession. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognition. [...]

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy, the facility failed to file and investigate a grievance per policy for one resident, #34.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that the resident #3 received adequate supervision during medication and treatment administration to prevent accidents. The sample size was 1. The deficient practice could result in medication errors and/or ingestion of hazardous materials.