Haven Health Sky Harbor: Abuse Report Delays - AZ

The incident involved a nurse who allegedly entered Resident #1's room while the person was half-dressed and began rubbing the resident's chest, claiming concern that the resident appeared "altered," according to inspection records from August 12, 2025.

The physical therapist's documentation of the incident should have triggered immediate reporting to administrators under federal nursing home regulations. Instead, the facility's director of nursing told inspectors she and the administrator only learned about the abuse allegation when Adult Protective Services contacted them weeks later.

"The allegation of abuse was not reported to her and to the administrator and that they both learned of the allegation of abuse on a later date from APS, and that is when they filed it to the department and to the law enforcement," the director of nursing told inspectors during an exit interview.

The administrator claimed they verified the incident with the resident and family member and "confirmed that nothing happened." The administrator stated the physical therapy note "was not reflecting the reality of what Resident #1 stated once Resident #1 and the family member were interviewed."

But the facility's own policy requires staff to "identify and investigate all possible incidents of abuse" and "investigate and report any allegations within timeframes required by federal requirements." The policy also mandates that the facility "protect residents from any further harm during investigations."

Unit coordinator Staff #65, who speaks Spanish and helps with translation, told inspectors she had translated for one of the unit managers regarding an incident in July. She understood her responsibility clearly: "if she hears any allegation of abuse, she will report it to the administrator."

Staff #65 explained the stakes to inspectors: "if abuse is not reported, the abuse allegation will not get investigated, the resident is vulnerable, and the resident would feel unsafe in the facility."

The breakdown in communication appears to have occurred between the physical therapist and facility leadership. Staff #55, identified as a unit coordinator, provided a different version of events when interviewed with translation assistance.

According to Staff #55's account, the nurse entered the room while Resident #1 was half-dressed and began rubbing the resident's chest out of concern that the resident appeared altered. Staff then placed the resident back in bed. Staff #55 told inspectors she "did not remember any other abuse incident, just this one for this year."

The director of nursing acknowledged speaking with the Director of Rehab about the physical therapist's note, though she could not remember when that conversation occurred. She also said she spoke directly with Resident #1, who "denied the accusation."

Despite these conversations, the director of nursing said she had concerns about medication administration during the incident. Those concerns prompted the administrator to eventually report the incident to police and the Department of Health Services in their mandatory five-day report.

The facility's reporting policy explicitly states that residents "have the right to be free from abuse" and requires immediate investigation of all possible incidents. Federal regulations mandate that nursing homes report suspected abuse within 24 hours to administrators and immediately to appropriate authorities.

The inspection revealed a communication breakdown that left a potential abuse allegation unreported for weeks. While administrators claim they investigated and found no wrongdoing, the delay in reporting prevented immediate protective measures and proper investigation protocols.

The wound care nurse who was supposed to visit Resident #1 initially encountered the resident eating lunch with a visitor, and the resident asked them to return later. This detail appears in the inspection report alongside the more serious allegations about the chest-rubbing incident.

Staff #55 specifically noted that the incident she translated involved a nurse trying to wake up Resident #1 by rubbing the resident's chest, but characterized this as the nurse being concerned about the resident's altered state rather than inappropriate contact.

The discrepancy between the physical therapist's documentation and staff accounts raises questions about what actually occurred and whether the facility's investigation was thorough enough to determine the truth.

Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "some" residents. However, the failure to report allegations promptly can have broader implications for resident safety throughout a facility.

The administrator's claim that the physical therapy note didn't reflect reality suggests either miscommunication about what the therapist observed or disagreement about how to interpret the nurse's actions with the half-dressed resident.

Unit coordinator Staff #65's clear understanding of reporting requirements contrasts sharply with the apparent failure of the physical therapist's concerns to reach facility leadership through proper channels.

The director of nursing's inability to remember when she spoke with the Director of Rehab about the incident suggests the facility may not have treated the allegation with appropriate urgency even after learning about it.

The facility ultimately filed reports with the department and law enforcement only after Adult Protective Services contacted them, indicating the state investigation preceded the facility's own reporting.

Resident #1's denial of the accusation, as reported by the director of nursing, came only after the facility learned about the allegation from outside investigators rather than through their own internal reporting systems.

The inspection found that Haven Health Sky Harbor failed to ensure immediate reporting of suspected abuse, potentially leaving residents vulnerable during the weeks between the initial incident and the eventual investigation.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Haven Health Sky Harbor, LLC from 2025-08-12 including all violations, facility responses, and corrective action plans.

Additional Resources

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