Haven Health Sky Harbor, LLC

In the surveyor’s words

From the most serious findings on record at Haven Health Sky Harbor, LLC, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 28, 2023

  Based on clinical record review, resident and staff interviews, facility documentation and policy, the facility failed to ensure one resident (#1) was free from sexual abuse. The deficient practice could increase risk of harm to other residents. Findings include: Resident #1 had an initial admission on June 7, 2019 and readmitted to the facility in a private room on September 9, 2022 with diagnoses of tracheostomy status, epilepsy (intractable with status epilepticus), major depressive disorder, and anoxic brain damage. The MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) Score of 15 indicating the resident was cognitively intact. […]

• Actual harm, isolatedF689Jun 4, 2021

  Based on clinical record review, interviews, and review of facility documentation and policies, the facility failed to ensure that one resident (#1) received adequate supervision to prevent the removal of the resident's [CONDITION(S)] ([CONDITION(S)]) tube. The facility census was 79 residents. The deficient practice could result in residents not receiving the supervision they require to remain safe. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute [CONDITION(S)], [CONDITION(S)], and acute kidney failure. Review of the resident's respiratory care plan dated [DATE], revealed that the resident had a [CONDITION(S)] related to impaired gas exchange, ineffective airway clearance, and respiratory insufficiency. […]

• Actual harm, isolatedF600May 14, 2021

  Based on clinical record review, staff interviews, and review of facility documentation, policies, and a personnel file, the facility failed to ensure one resident (#1) was free from neglect. The deficient practice could result in residents being neglected by staff. The census was 84 residents. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per an admission functional assessment dated [DATE], the resident was dependent on staff for incontinence care and rolling in the bed from right to left side. In a review of a skilled/look back documentation dated April 24, 2021, the resident was assessed to be totally dependent on staff for bed mobility with a 2 person plus physical assist. […]

• No harm, potential for more than minimal, patternF550Nov 13, 2025

  Based on a review of the clinical record, staff interviews, and policies and procedures, the facility failed to ensure that residents were treated with dignity and respect during meal service for four out of six residents observed receiving dining assistance (Residents #10, #61, #72, and #107). The universe was 106, and the sample size was 22. This deficient practice could potentially affect all residents needing meal assistance by diminishing their sense of dignity and personhood.-Regarding Resident #10Resident #10 was admitted on [DATE], with the diagnosis that included chronic respiratory failure with hypoxia, tracheostomy status, quadriplegia, C1-C4 incomplete, hypertensive heart disease without heart failure, generalized anxiety disorder, major depressive disorder, recurrent… […]

• No harm, potential for more than minimal, patternF842Nov 13, 2025

  Based on a review of the clinical record, staff interviews, and a review of policies and procedures, the facility failed to maintain and make accessible complete medical records necessary to investigate the cases of 7 residents reviewed (Resident #137, #138, #139, #140, #141, #142, and #144). The universe was 106, and the sample size was 22. The deficient practice prevented a thorough investigation and posed a potential risk to the current quality and safety of resident care.-Regarding Resident #137Resident #137 was admitted on [DATE], with a diagnosis that included osteomyelitis, pressure ulcer of the right lower back, unspecified stage, and central cord syndrome at C4, subs. […]