Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Of Phoenix during CMS and state inspections, most recent first.
Failure to Protect Residents from Resident-to-Resident Physical Abuse: Two separate resident-to-resident altercations were documented, including one involving a confused resident with severe cognitive impairment who struck a roommate over a walker and another in which a resident with dementia hit another resident with his fists after striking him with a power wheelchair. Staff interviews and records confirmed the physical confrontations, and the DON acknowledged that one resident hitting another resident would be considered physical abuse.
PRN pain medications were administered outside ordered pain-score parameters for two residents. One resident with psychiatric diagnoses received oxycodone-acetaminophen when documented pain was below the ordered 6 to 10 range, and another resident with dysphagia, GERD, HTN, and anxiety received oxycodone HCl when documented pain was above the ordered 4 to 6 range. LPNs and the DON confirmed the MAR entries did not match the physician orders, and the facility policy required medications to be given in accordance with prescriber orders.
Hand hygiene and infection control failures occurred during meal service and blood glucose testing. A CNA handled dirty dishes, assisted residents with breakfast, and filled a resident’s coffee cup without sanitizing hands between residents. In a separate event, an RN performed a blood sugar check on a resident on contact isolation for C-diff, MRSA, wounds, and an indwelling catheter, used a glucometer from the med cart, and disinfected it with hand sanitizer and tissue instead of the validated disinfectant wipe; the glucometer was then returned to the cart.
PASRR Level 2 Referral Not Submitted or Documented: The facility failed to update and accurately submit PASRR information for a resident with SMI and mood disorder diagnoses. The resident’s PASRR identified bipolar disorder and schizoaffective disorder as SMI, but no record showed that a Level 2 referral was submitted to AHCCCS. Staff interviews confirmed the referral could not be verified, and the facility’s tracking form listed PASRR issues including missing admission PASRRs, Level 2 not submitted or identified, and missing documentation of Level 2 determinations.
Pain Medication Not Given Per Ordered Parameters: A resident recovering from hip surgery with fibromyalgia had PRN pain meds ordered by pain level, but the MAR showed repeated instances where staff gave the wrong dose or wrong medication for the documented pain score. The resident said she was screaming in pain, used her call light every 4 hours, and felt ignored. An LPN and the acting DON both described that meds should be administered according to the physician’s order and pain parameters, but the documented administrations did not match those orders.
Incomplete daily nurse staffing postings failed to include all required data elements. The staffing board listed counts of CNAs, RNAs, RNs, LPNs, and med techs by shift, but it did not include a place for actual hours worked, and review of staffing reports showed repeated missing actual-hours calculations. The Staffing Coordinator, interim DON, and ED all stated they were unsure of the posting requirements, and the ED reported there was no policy or procedure for the staffing posting data requirements.
A resident with intact cognition and diagnoses including dysphagia, GERD, HTN, and anxiety had a Soursop supplement left on the bedside table even though there was no documented IDT assessment or self-administration approval. The resident said he ordered and took the supplement himself, while an LPN later confirmed it was not supposed to be unattended at the bedside and found no order in the chart; a later provider order specified clinician-only administration.
A resident with a history of fall risk and dependence on hemodialysis was injured during van transport when the driver failed to properly secure the wheelchair and resident, and accelerated onto an expressway. The unsecured resident tipped back, striking her head, shoulders, and knees, resulting in a scalp hematoma and a fractured vertebra. Staff interviews and documentation confirmed that required safety procedures for securing residents were not followed.
A resident with serious health conditions was not provided with necessary oxygen therapy, leading to a critical situation where the resident was found unresponsive. Staff delayed calling 911 and performed CPR inaccurately, resulting in the resident's death. Interviews revealed inconsistent vital sign monitoring and poor emergency response coordination.
A facility failed to report an allegation of abuse to the state survey agency and did not complete a timely investigation. A resident with cognitive impairments reported being inappropriately touched by another resident. Despite the report, the facility did not notify the state agency, believing the incident was a delusion. The DON confirmed that such allegations should be reported within two hours, but the facility's policy was not followed, leading to a deficiency.
The facility failed to provide adequate supervision, leading to incidents involving inappropriate behavior and altercations among residents. A resident with dementia and a history of inappropriate advances was involved in multiple incidents, including a physical altercation in a congested hallway and inappropriate touching in the dining room. Another resident with behavioral issues was involved in the altercation, and a third resident with cognitive impairment was inappropriately touched. The lack of supervision and documentation contributed to an unsafe environment.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that two residents were protected from resident-to-resident abuse. One incident involved a resident with diagnoses including encephalopathy, anxiety, and bipolar disorder, who had a BIMS score of 2 indicating severe cognitive impairment. According to the record, this resident became physically aggressive toward a roommate over a walker, screamed that it was his, and struck the roommate in the right upper extremity. Staff separated the residents, removed the aggressive resident from the room, notified the provider, and transferred him to the hospital for further evaluation and care. The roommate involved in that altercation had diagnoses including sepsis, type 2 diabetes, and cellulitis, and had a BIMS score of 14 indicating intact cognition. The resident reported that the other resident used his walker, pulled him, and punched him multiple times on the right wrist, and that he had right shoulder pain. Staff interviews described the event as a physical altercation over a walker, with both residents yelling and fighting, and one CNA stated that both residents were physically fighting and making threats. The Interim DON stated that one resident hitting another resident would not be considered abuse, despite other staff stating that it would be considered physical abuse. A second incident involved a resident with diagnoses including type 2 diabetes, vascular dementia, mood disorder, and anxiety, with a BIMS score of 15 indicating intact cognition. Staff documentation stated that this resident was witnessed hitting another resident with his fists after running into him with a power wheelchair from behind, striking him on the knee and face. The other resident had diagnoses including type 2 diabetes, adjustment disorder, and mood disorder, and had a BIMS score of 13 indicating intact cognition. Records and interviews confirmed that staff witnessed the physical altercation, both residents were assessed, and no injuries were noted, while the DON later stated that one resident hitting another resident would be considered physical abuse.
PRN Pain Medications Given Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for two residents who had PRN oxycodone orders tied to specific pain-score parameters. Resident #32 was readmitted with diagnoses including schizoaffective disorder, bipolar disorder, major depressive disorder, and anxiety disorder, and had a care plan focus for polyneuropathy pain with interventions to anticipate pain relief needs and respond as soon as possible. The physician ordered oxycodone-acetaminophen 325 mg every 5 hours as needed for pain levels of 6 to 10, but the April 2026 MAR showed the medication was given on multiple occasions when the documented pain level was below the ordered range, including pain levels of 5, 2, 4, 2, and 5. Resident #56 was admitted with diagnoses including dysphagia, GERD without esophagitis, hypertension, and anxiety, and had intact cognition with a BIMS score of 15. The physician ordered oxycodone HCl 5 mg every 6 hours as needed for pain scale 4 to 6 related to low back pain, and the care plan identified the resident as at risk for pain with analgesia to be administered per orders. The April 2026 MAR showed the medication was administered on multiple occasions when the documented pain level was above the ordered range, including pain levels of 7 and 8 on several dates. Interviews with LPNs and the interim DON confirmed that staff were expected to assess pain level, verify the order, and administer pain medication according to the ordered parameters. Staff reviewed the records and stated that the documented administrations for both residents were outside the physician-ordered pain ranges. The facility policy titled, Medications: Administering Medications, stated that medications are to be administered in accordance with the prescriber's orders, including any required time frame.
Hand Hygiene and Glucometer Disinfection Failures
Penalty
Summary
The facility failed to ensure proper hand hygiene during meal service. During an observation in the dining room, a CNA assisted residents at breakfast, removed used dishes from tables, scraped plates, and handled dirty tray carts without performing hand hygiene between residents. The CNA then pulled a new breakfast tray for a resident, placed the dish and silverware in front of the resident, sat beside the resident, picked up the fork, placed eggs on it, and fed the resident. The CNA also cleared dishes from another resident’s table, handled the garbage can and dirty tray cart, and then filled a coffee cup for another resident without sanitizing his hands. He also placed his fingers on the top of the coffee mug before returning it to the resident. The CNA stated that he did not perform hand hygiene during the dining service and identified the risk as cross contamination and spreading disease. The Assistant Food Director stated that staff were expected to sanitize their hands between assisting residents and that the risks could include foodborne illness and spreading germs between residents. The acting DON stated that it did not meet expectation for staff to not perform hand hygiene between residents and that education was needed based on the observation. The facility also failed to follow infection control procedures during point of care blood glucose testing for a resident with C-diff, MRSA, an indwelling urinary catheter, wounds, and a PICC line. The resident was on Enhanced Barrier Precautions and contact isolation precautions. During the blood sugar check, the RN entered the room with a glucometer from the medication cart, wore a gown and gloves, and performed the fingerstick while the glucometer was placed on the resident’s bedside table. After leaving the room, the RN carried the glucometer back to the medication cart and stated that she used a tissue paper with hand sanitizer to wipe it down and then dried it with another tissue paper before placing it in the cart drawer. The acting DON stated that for a resident on contact isolation due to C-diff, staff should gown up and use gloves, leave devices such as a glucometer inside the resident’s room, and use a disinfectant wipe rather than hand sanitizer to disinfect the glucometer.
PASRR Level 2 Referral Not Submitted or Documented
Penalty
Summary
The facility failed to ensure that PASRR information was updated appropriately and accurately submitted for one resident with diagnoses that included schizoaffective disorder, bipolar disorder, major depressive disorder, and anxiety disorder. The resident was readmitted to the facility and had a 5-day MDS assessment in which the BIMS was not assessed, followed by a quarterly MDS showing a BIMS score of 15.0, indicating cognitive intactness. That same assessment documented no behavioral symptoms, daily rejection of care behavior, active psychiatric or mood disorder diagnoses, and use of antianxiety and antidepressant medications. The resident’s PASARR was completed and identified bipolar disorder and schizoaffective disorder as serious mental illness diagnoses, with anxiety disorder and depression selected as mental disorders. However, no document was found in the resident’s medical record showing that a Level 2 referral for determination was submitted to the appropriate state agency program. The resident’s care plan later documented diagnoses of major depressive disorder, anxiety disorder, and schizoaffective disorder, with interventions related to specialized mental health services, behavioral monitoring, and reporting changes to the provider. During interviews, the Resident Relations Manager stated that PASARRs were completed on admission and that a Level 1 and Level 2 PASARR would be completed if a resident stayed in the facility for 30 days. She also stated that she could not find an email document showing that a referral was sent to AHCCCS for this resident. She further stated that she had audited residents with SMI and had not gotten far in double-checking whether residents met Level 2 criteria. The Executive Director later provided a document titled PASRR Documentation of past noncompliance, which included a quality tracking form identifying problems such as admission PASRR not obtained within 72 hours, PASRR Level 2 not submitted or identified, and failure to verify and maintain documentation of PASRR Level 2 determination.
Pain Medication Not Given Per Ordered Parameters
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #137, who was admitted after joint replacement surgery and had fibromyalgia. The resident’s BIMS score on 05/03/2026 was 12, indicating moderate impairment. The physician ordered Hydrocodone-Acetaminophen 5-325 mg, 1 tablet every 4 hours as needed for pain rated 4-6, 2 tablets every 4 hours as needed for pain rated 7-10, and Ibuprofen 200 mg, 3 tablets every 4 hours as needed for pain rated 1-3. The care plan identified that the resident was on an opiate medication and directed staff to administer medication as ordered. The May 2026 MAR showed multiple instances where the medication given did not match the ordered pain parameter. On 05/02/2026 at 2:28 AM and 6:32 AM, the resident’s pain was documented as 7, but 1 tablet of Hydrocodone-Acetaminophen was administered instead of 2 tablets. On 05/02/2026 at 12:01 PM, the resident’s pain was documented as 7, but Ibuprofen was given instead of Hydrocodone-Acetaminophen 2 tablets. On 05/02/2026 at 9:50 PM and 05/03/2026 at 2:00 AM, the resident’s pain was documented as 8, but 1 tablet of Hydrocodone-Acetaminophen was administered instead of 2 tablets. On 05/03/2026 at 4:44 AM, the resident’s pain was documented as 6, but Ibuprofen was given instead of Hydrocodone-Acetaminophen 1 tablet. During interview, the resident stated she had been screaming in pain after hip surgery and used her call light every 4 hours for pain medication but staff came late and she felt ignored. The LPN stated she would check the resident’s pain level, review the ordered medication, and administer medication as ordered, but also described giving a different pain medication or documenting when the resident requested something other than the ordered parameter. The acting DON/ADON stated staff were expected to follow physician orders, and specifically stated that if the resident had a pain level of 7-10, she should have received 2 tablets of Hydrocodone-Acetaminophen as ordered; she also stated that giving 1 tablet for a pain level of 10 did not follow the physician’s order.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information posted included all required data elements. On May 3, 2026, an observation of the staffing posting showed the number of CNAs, RNAs, RNs, LPNs, and medication technicians by shift, but there was no area for the actual hours worked by staff to be completed. A review of randomly selected staffing postings compared with staff assignment sheets showed that none of the postings matched the actual number of staff who worked. Review of Daily Staffing reports showed missing data requirements on multiple dates, including no evidence of calculation of actual hours reflected on the staff posting for several days in May 2025, August 2025, September 2025, and January 2026. During interviews, the Staffing Coordinator stated that the postings included staffing counts and that actual hours were stored on an internal database, but she was unsure whether actual hours were required on the postings. The interim DON stated she was unsure what data requirements had to be included and what risk missing information could present. The ED stated there was no policy or procedure in place regarding staff posting data requirements and was also unaware that actual hours worked were to be included.
Medication Left at Bedside Without Self-Administration Approval
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for one resident. Resident #56 was admitted with diagnoses including dysphagia, gastro-esophageal reflux disease without esophagitis, hypertension, and anxiety. An admission evaluation record dated November 18, 2026, indicated the resident did not desire to self-administer drugs, and a quarterly MDS assessment showed a BIMS score of 15, indicating intact cognition. There was no evidence in the progress notes of an IDT meeting related to medication self-administration. During an observation of the resident's room on May 03, 2026, a bottle of Soursop supplement for gut health was seen on the bedside table. The resident stated that the Soursop supplement was not a medication, that it was a supplement, and that he had ordered and administered it himself. An LPN later stated the supplement was not supposed to be left unattended at the bedside and removed it from the room, then found no order for the supplement in the clinical record. A physician order was later written for Soursop, to give 30 milligrams after breakfast daily, one time a day for supplement, administered by clinician only. The DON stated the facility process for self-administration required an IDT assessment and provider order, and confirmed there was no documentation showing Resident #56 had been assessed for self-administration.
Failure to Properly Secure Resident During Transport Results in Injury
Penalty
Summary
A deficiency occurred when a facility failed to ensure the safety of a resident during transport by not properly securing the resident in a wheelchair-accessible van and failing to maintain a safe speed. The resident, who had a history of generalized weakness, was at risk for falls and was dependent on hemodialysis. The care plan for this resident included interventions for fall risk and anticoagulant therapy, but these were not effectively implemented during the transport event. During the incident, the van driver accelerated onto an expressway, causing the unsecured resident to tip back in her wheelchair and strike her head, shoulders, and knees against the van lift rails. Documentation and interviews revealed that the driver did not properly use the required straps and seat belt to secure the resident and wheelchair, as outlined in facility policy and training. The driver admitted uncertainty about the use of the straps and acknowledged that the resident was not strapped down properly at the time of the incident. As a result of the incident, the resident sustained a scalp hematoma, pain in both shoulders and knees, and was later found to have a fractured vertebra. The facility's investigation confirmed that all van equipment was functioning properly and that the driver had previously received safety training. Staff interviews corroborated that the driver failed to follow established procedures for securing residents during transport, directly leading to the resident's injuries.
Failure to Provide Adequate Emergency Response and Oxygen Therapy
Penalty
Summary
The facility failed to ensure that care was provided according to professional standards for a resident with multiple serious health conditions, including acute chronic heart failure and severe sepsis. The resident had orders for oxygen therapy to maintain oxygen saturation above 90%, but the care plan did not include a plan for oxygen therapy. Documentation revealed that the resident's oxygen saturation was critically low at 77% on a specific date, yet there was no record of oxygen therapy being administered as ordered. This lack of adherence to the prescribed care plan contributed to the resident's deteriorating condition. On the day of the incident, the resident was found unresponsive by a CNA during routine checks. The CNA initiated CPR but did not provide breaths due to the lack of a mouthpiece. The LPN was called to assist, but there was a delay in calling 911, with staff waiting 15 minutes before making the call. When the EMTs arrived, they found the staff performing CPR inaccurately, with improper use of the bag-valve-mask and no oropharyngeal airway in place. The EMTs noted that the resident's blood sugar was critically low, and despite their efforts, the resident was pronounced dead shortly after their arrival. Interviews with staff revealed a lack of consistent vital sign monitoring during the night shift and confusion regarding CPR procedures. The CNA stated that vitals were typically checked only during the day and evening shifts, and there was no clear protocol for handling emergencies during the night. Additionally, there was a lack of communication and coordination among staff during the emergency, with some staff not using radios and others not returning to assist after calling 911. The facility's policy on emergency procedures was not followed, contributing to the inadequate response to the resident's critical condition.
Failure to Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency and did not complete and submit a 5-day written investigation in a timely manner. This deficiency was identified when Resident #17, who has impaired cognitive function, reported being touched inappropriately by another resident, Resident #8, who also has cognitive impairments. The incident was reported to the Assistant Director of Nursing, who conducted an interview with Resident #17, leading to the identification of Resident #8 as the alleged perpetrator. Despite this, the facility did not report the incident to the state agency as required. The Administrator in Training admitted that the facility did not report the allegation, as they believed the incident was a result of Resident #17's delusional phase. The Director of Nursing confirmed that such allegations should be reported within two hours of awareness. The facility's policy mandates that abuse allegations be reported to several entities, including the state survey agency, but this protocol was not followed. The failure to report and investigate the allegation as per regulatory requirements constitutes a deficiency in the facility's handling of the situation.
Inadequate Supervision and Safety Hazards in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and ensure a safe environment for residents, leading to multiple incidents involving inappropriate behavior and physical altercations. Resident #26, who has a history of dementia and inappropriate sexual advances, was involved in several incidents. On one occasion, he made sexual advances towards a staff member, and on another, he was involved in a physical altercation with Resident #5 in a congested hallway. The hallway was obstructed by a medication cart and an empty wheelchair, which contributed to the altercation. Resident #26 was also reported to have inappropriately touched Resident #3 in the dining room, an incident that was not documented in the progress notes. Resident #5, who has a history of behavioral problems and is on opiate medication for chronic pain, was involved in the altercation with Resident #26. She reportedly struck Resident #26 in the chest after he attempted to pass her in the hallway. Interviews revealed that Resident #5 has expressed dislike for Resident #26 and has a history of mumbling about hating people and wanting to hit them. Despite these behavioral issues, there was no evidence of adequate supervision or intervention to prevent the altercation. Resident #3, who has moderate cognitive impairment, was inappropriately touched by Resident #26 in the dining room. The incident involved Resident #26 tickling Resident #3, who expressed discomfort and asked him to stop. Although a CNA intervened, the incident was not initially documented in the progress notes. Interviews with staff and residents highlighted a lack of supervision and failure to address Resident #26's inappropriate behavior, contributing to an unsafe environment for the residents involved.
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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) |
|---|---|---|---|---|
| The Rehabilitation Center At The Palazzo | 2.2 mi | ★★★★★ | 1 | 0 |
| Beatitudes Campus | 2.9 mi | ★★★★★ | 0 | 0 |
| Camelback Post Acute Care And Rehabilitation | 2.9 mi | ★★★★★ | 3 | 0 |
| Maryland Gardens Post Acute | 2.9 mi | ★★★★★ | 10 | 0 |
| Desert Terrace Healthcare Center | 4.3 mi | ★★★★★ | 7 | 0 |
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