Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Health Sky Harbor, Llc during CMS and state inspections, most recent first.
A resident with dementia, moderate cognitive impairment (BIMS 8), gait and mobility deficits, and documented wandering/exit-seeking behaviors eloped after being last seen by an LPN during morning meds and stating he was going to the dining room. Despite prior notes identifying wandering and elopement risk as barriers to discharge and care plans addressing dementia and behavior problems, a wander risk assessment was not completed on admission. Video showed the resident at the front door with no staff present until a security officer arrived from outside, misidentified the resident as a visitor based on brief questioning, and allowed him to exit. The resident then left the property and was later located and returned by family, while the facility’s investigation found that security failed to follow protocols for verifying whether the individual leaving was a visitor or a resident.
The facility did not maintain or provide complete medical records, including care plans, progress notes, orders, MAR/TAR, CNA care tasks, and assessments, for several residents with complex medical needs. When documentation was requested for specific periods and incidents, facility leadership stated that records prior to a change in ownership were unavailable, leaving only MDS and face sheets accessible. This lack of documentation prevented a thorough investigation into the care provided, as required by regulations.
Dignity Not Maintained During Assisted Dining: Staff were observed standing while assisting residents with meals, including assisting two residents at once, rather than providing seated, respectful one-on-one support. Staff also used the term “feeders” to describe residents needing help with eating. The DON, care coordinator, and facility policy all identified that assisted dining should be provided with dignity and that labels such as “feeders” should not be used.
A resident with moderate cognitive impairment alleged that a CNA held a dirty brief close to her face, which was reported by a therapy staff to the DON. Although the facility's policy required reporting suspected abuse to authorities within two hours, mandated reporting to the State Agency was delayed until the following day, resulting in a failure to meet regulatory requirements for timely reporting.
A resident with glaucoma was admitted with discharge orders to continue two eye drops, including bimatoprost (Lumigan), but the MAR did not show an active order for the bimatoprost. The resident said the medication had been used for years and was not given despite requests. The admitting LPN later acknowledged the order was inadvertently omitted from the EHR, and the DON stated both eye drops should have been transcribed and administered as ordered.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not maintain complete and accurate documentation regarding the deaths of two residents, including missing vital sign records and incomplete entries in both electronic and paper medical records, despite facility policy requiring thorough documentation of such events.
A resident with moderate cognitive impairment and multiple diagnoses reported an incident during incontinence care, leading to a request for two female caregivers. Despite the facility's investigation and the resident's preference, the care plan was not updated to reflect this change, resulting in a deficiency. The Director of Nursing acknowledged the oversight, as the change was only noted in the electronic medical records, not the care plan.
A ventilator-dependent resident was transferred to an out-of-state hospital without proper documentation or communication. The facility failed to provide a physician's order for the transfer, and the receiving hospital was not informed until the resident was en route. The resident's family was also not notified, leading to the resident being admitted to the ICU without prior arrangement.
A resident with multiple diagnoses did not receive their prescribed medications as ordered due to lapses in the facility's medication administration process. Despite protocols to ensure medication availability, the medications were not administered, and there was insufficient documentation explaining the issue.
Failure to Prevent Elopement of Resident With Known Wandering Risk
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for a resident with known cognitive impairment and wandering behaviors. The resident had multiple diagnoses including metabolic encephalopathy, dementia with agitation, cognitive communication deficit, gait and mobility abnormalities, and generalized muscle weakness. An admission MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and documented wandering behaviors occurring one to three times during the assessment period. The MDS also indicated the resident required supervision or touching assistance for transfers and ambulation and used both a walker and wheelchair. The care plan included a focus on dementia with interventions to monitor and report changes in cognition, and a separate focus on functional self-care and mobility limitations. Another care plan focus identified behavior problems including wandering and exit-seeking behaviors, resistance to care, and non-compliance, with interventions to anticipate needs and provide education. Progress notes prior to the incident documented ongoing wandering behavior. A daily skilled evaluation note indicated the resident wandered in the hallway and appeared restless in his room, and another note documented wandering behaviors with instructions that staff were to anticipate his needs. A skilled needs review identified dementia, wandering, and elopement risk as barriers to discharge planning. Despite these documented behaviors and risks, the resident’s wander risk evaluation was not completed upon admission. The DON later acknowledged that the resident’s wandering assessment was not documented at the time of admission, even though the resident had been care planned for these issues. On the day of the elopement, the resident’s blood sugar was checked and morning medications were administered around 7:00 a.m., and a progress note stated he was last seen at approximately 8:00 a.m. during the morning medication pass, when he told the LPN he was going to the dining room to wait for breakfast. Video surveillance from that morning showed the resident at the front entrance at 7:27 a.m., with no staff present in the lobby or at the door. The resident was seen attempting to push and pull on the locked exterior door until a security officer approached from outside. The security officer, who was unaware of the resident’s wandering history and did not recognize him as a resident, asked if he was visiting someone; the resident nodded yes and stated he was going to the second floor. The security officer then allowed him to exit and observed him outside for approximately two minutes before he left the property. The receptionist, who on other days controlled the front door and was aware of the resident’s wandering tendencies, was not on duty at the time. The resident subsequently left the premises, boarded a city bus, and was later located and returned to the facility by a family member, confirming that the resident had been away from the facility for an extended period without supervision. The facility’s own five-day investigation determined that the security guard did not follow standards and protocol for verifying whether the individual leaving the facility was a visitor or a resident, and the elopement was substantiated. The facility’s policy on wandering and elopements stated that residents at risk of unsafe wandering would be identified and that staff observing a resident leaving the premises should attempt to prevent the resident from leaving in a courteous manner. In this incident, the resident’s known wandering and elopement risk, the lack of a completed wander risk assessment at admission, the absence of staff monitoring at the front entrance, and the failure of the security officer to correctly identify and stop the resident from exiting the building all contributed to the resident’s unsupervised departure from the facility.
Failure to Maintain and Provide Complete Medical Records
Penalty
Summary
The facility failed to maintain and make accessible complete medical records for seven residents, as required for thorough investigation and in accordance with accepted professional standards. During the review, it was found that essential documentation such as care plans, progress notes, physician orders, medication administration records (MAR/TAR), CNA care tasks, shower sheets, pressure ulcer and wound assessments, skin assessments, and change of condition assessments were missing for multiple months relevant to the residents' care. This lack of documentation was identified for residents with complex medical histories, including diagnoses such as osteomyelitis, pressure ulcers, fractures, diabetes, chronic respiratory failure, and mental status changes. The deficiency was further highlighted when documentation requests were made for specific time periods and incidents, but the facility was unable to provide the required records. The Director of Nursing and the Administrator stated that documentation prior to the facility's acquisition was unavailable, and only the Minimum Data Set (MDS) and face sheets could be provided. This lack of accessible records included not only resident care documentation but also employee records for staff who had worked during the relevant periods. A review of the facility's policy on medical record retention indicated that records should be maintained in accordance with state and federal laws. However, the facility's inability to produce the necessary documentation for the specified residents and timeframes prevented a thorough investigation into the care provided, as required by regulatory standards.
Dignity Not Maintained During Assisted Dining
Penalty
Summary
The facility failed to ensure that residents receiving meal assistance were treated with dignity and respect during dining service. During a lunch observation, three staff members were seen assisting four residents while standing. One staff member stood between two residents and assisted both at the same time, another stood while preparing one resident’s setup before sitting down, and another stood next to a resident while completing setup and meal assistance. Resident #10 had diagnoses including chronic respiratory failure with hypoxia, tracheostomy status, quadriplegia, hypertensive heart disease without heart failure, generalized anxiety disorder, major depressive disorder, recurrent adjustment disorder, and schizoaffective disorder, bipolar type. Resident #61 had diagnoses including polyneuropathy, type 2 diabetes mellitus with hyperglycemia, paroxysmal atrial fibrillation, adjustment disorders, major depressive disorder, recurrent, and neuromuscular dysfunction of the bladder. Resident #72 had diagnoses including chronic kidney disease, dependence on renal dialysis, essential hypertension, hyperlipidemia, anemia, and thrombocytopenia. Resident #107 had diagnoses including unspecified psychosis, cerebral infarction, hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, other paralytic syndrome following cerebral infarction, bilateral muscle weakness, and type 2 diabetes mellitus without complications. Each of these residents had care plans that included assisted dining or one-on-one dining assistance. Staff interviews showed that the term “feeders” was used by staff to describe residents who required help with eating, and staff described assisted dining as sitting next to the resident and providing slow, respectful assistance. One LPN stated that staff should not rush residents and that standing over residents could diminish dignity and self-respect. The care coordinator stated that the term “feeders” should not be used because it can pose a concern to a resident’s dignity, and the DON stated that staff should be seated rather than standing when assisting with meals and that the term “feeder” should not be used at all. The facility policy also stated that residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity, including not standing over residents and avoiding labels such as “feeders.”
Failure to Timely Report Alleged Abuse to Mandated Entities
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported to mandated entities within the required 2-hour timeframe. The incident involved a resident with moderate cognitive impairment, who reported to a physical therapy assistant that a CNA had held a dirty brief close to her face during care, which the resident described as emotionally hurtful. The physical therapy assistant stated she reported the allegation to the DON within two hours of hearing it, but the facility's self-report to the State Agency was not submitted until the following day. Multiple staff interviews and documentation revealed inconsistencies regarding when the allegation was first reported and when the mandated reporting occurred. The DON and Administrator both stated that the report to authorities was made the same day the therapist brought the allegation forward, but time records and staff statements indicated that the incident was reported to the DON on one day and to the State Agency the next day. The facility's own investigation documents and interviews with involved staff confirmed that the initial report to the DON occurred on one date, but the mandated external reporting was delayed beyond the required 2-hour window. The resident involved had a history of moderate cognitive impairment and was admitted with multiple diagnoses, including malignant neoplasm of the colon and atrial fibrillation. The facility's policy required immediate reporting of suspected abuse to the administrator and mandated entities within two hours, but this protocol was not followed in this case. The delay in reporting could have impacted the timeliness and effectiveness of the investigation into the abuse allegation.
Glaucoma Eye Drop Order Omitted on Admission
Penalty
Summary
The facility failed to ensure that a resident with a history of glaucoma received glaucoma medication according to admission orders. The resident was admitted with diagnoses including unspecified glaucoma, and the hospital history and physical documented home use of brimonidine 0.1% ophthalmic solution and bimatoprost 0.01% ophthalmic solution. The hospital discharge orders directed continuation of both eye drops, and a physician order was entered for brimonidine tartrate 0.1% solution to be instilled in both eyes twice daily for eye pressure. Review of the MAR showed no active, hold, or discontinue order for bimatoprost ophthalmic 0.01% solution, and the admission care plan had no focus for vision impairment or glaucoma needs. The resident stated that Lumigan (bimatoprost ophthalmic 0.01%) had been used for years and that the medication was not given despite the resident saying it was needed. The admitting LPN stated the discharge orders were transcribed into the electronic record and later acknowledged that the bimatoprost order had been inadvertently omitted. The DON stated both eye drops should have been transcribed and administered as ordered, and the resident could be a reliable source for home medications.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency is based on the observation that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting procedures were not followed as mandated. The report specifically notes the lack of timely communication and documentation to the appropriate authorities regarding both the suspicion and the outcome of the internal investigation.
Failure to Maintain Accurate Documentation of Resident Deaths
Penalty
Summary
The facility failed to maintain accurate and complete documentation regarding the deaths of two residents. For one resident with a history of malignant neoplasm and on hospice care, the progress notes indicated the time of death and confirmation by nursing staff, but there were no vital signs recorded on the date of death in the blood pressure and pulse summaries. The facility's Director of Nursing (DON) confirmed that documentation related to such events should be present in the electronic health record, including any additional documentation such as the release of human remains, but this was not consistently found. For the second resident, who had diagnoses including atrial fibrillation, cerebral infarction, and COPD, the records showed that the resident was found unresponsive and a rapid response code was initiated. Chest compressions and use of an AED were documented, with emergency services arriving and pronouncing the resident deceased. However, there were no vital signs recorded on the date of death except for one entry earlier in the day, and the DON stated that the facility was unable to locate any documentation surrounding the death in either the electronic or paper records. Facility policy requires that all information pertaining to a resident's death be recorded in the nurses' notes and that any changes in a resident's condition be documented in the medical record. Despite these policies, the facility was unable to provide complete documentation for the deaths of the two residents, as required by their own procedures and accepted professional standards.
Failure to Update Care Plan According to Resident Preferences
Penalty
Summary
The facility failed to update the care plan for a resident with moderate cognitive impairment, who was admitted with diagnoses including unilateral primary osteoarthritis, epilepsy, mood affective disorder, psychosis, and adjustment disorder. Following a complaint investigation, the resident reported an incident involving a CNA during incontinence care, which led to a request for two female caregivers for such care. Although the facility's investigation concluded the allegation was unsubstantiated, it was noted that the care plan should be updated to reflect the resident's preference for two female caregivers. Despite the investigation's findings, the care plan was not revised to include the requested change. Instead, an alert was placed in the electronic medical records, which the Director of Nursing acknowledged was not sufficient. This oversight was identified during a review of the care plan, which had been revised on a previous date but did not incorporate the resident's specific request. The failure to update the care plan as per the resident's preferences was a deficiency, as it did not align with the State Operations Manual requirements for resident participation in care planning.
Inadequate Transfer Process for Ventilator-Dependent Resident
Penalty
Summary
The facility failed to ensure a safe and appropriate transfer of a resident, leading to a deficiency in the transfer process. The resident, who was ventilator-dependent and had multiple medical conditions including cerebral palsy and chronic respiratory failure, expressed a desire to return to an out-of-state facility closer to family. Despite the resident's wishes, the facility did not adequately document or communicate the transfer details to the receiving hospital, resulting in a lack of coordination and preparation for the resident's arrival. The resident's transfer was initiated without a physician's order, and there was no evidence of communication with the receiving hospital regarding the resident's medical needs and condition. The facility's documentation did not include the name of the receiving provider or confirmation that a discharge summary and instructions were received. The receiving hospital was unaware of the resident's transfer until notified by the ambulance crew shortly before arrival, and the resident's family was not informed of the transfer until contacted by the hospital. Interviews with facility staff revealed that the discharge process was not properly managed, with no report given to the receiving facility and inadequate documentation of the transfer. The facility's policy required written notification and communication of transfer details, which were not followed in this case. The lack of proper documentation and communication led to the resident being admitted to the ICU for ventilation management without prior arrangement or acceptance by the receiving hospital.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for one resident. Resident #400, who had a history of cerebral infarction, myalgia, hyperlipidemia, polyneuropathy, and gastro-esophageal reflux disease, was admitted with specific medication orders. These included Atorvastatin, Gabapentin, and Methocarbamol. However, on March 29, 2024, the electronic Medication Administration Record (eMAR) indicated that these medications were not administered as scheduled, citing reasons such as awaiting pharmacy delivery and other unspecified issues. Interviews with various staff members, including LPNs, the Assistant Director of Nursing (ADON), and the pharmacy consultant, revealed inconsistencies and gaps in the medication administration process. The LPNs stated that the facility had protocols to ensure medications were available, including checking emergency kits (e-kits) and the Pyxis machine, and contacting the pharmacy for STAT orders if necessary. Despite these protocols, the medications for Resident #400 were not administered as ordered, and there was a lack of detailed documentation explaining why the medications were unavailable or what steps were taken to resolve the issue. Further investigation showed that the medications were delivered to the facility on the morning of March 29, 2024, but were not administered at the scheduled times later that day. The ADON confirmed that the medications should have been available and administered as ordered, and that the provider should have been notified if there were any issues. The facility's policies on medication administration and documentation were not followed, leading to the resident missing critical doses of their prescribed medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desert Terrace Healthcare Center | 1.7 mi | ★★★★★ | 7 | 0 |
| Desert Haven Care Center | 2.3 mi | ★★★★★ | 10 | 0 |
| Camelback Post Acute Care And Rehabilitation | 3.7 mi | ★★★★★ | 1 | 0 |
| Resolve Harmony Center, Llc | 4.1 mi | ★★★★★ | 26 | 0 |
| Haven Of Phoenix | 4.7 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.