Haven of Phoenix

In the surveyor’s words

From the most serious findings on record at Haven of Phoenix, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 16, 2025

  Based 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.Findings include:Resident #5 was admitted to the facility on [DATE], and discharged on December 28, 2023, with a diagnosis including infection and inflammatory reaction due to internal left knee prosthesis, subsequent encounter, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end-stage renal disease, and dependence on renal dialysis.Review of the Care Plan, date-initiated December 18, 2023, revealed a focus for fall risk related to… […]

• No harm, potential for more than minimal, patternF600May 6, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF684May 6, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF880May 6, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF680Jan 24, 2025

  Based 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. […]