Haven Health Sky Harbor, Llc

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

described the male staff looking Hispanic and that is how Staff #55 figured it was Staff #249 and he was with a CMA (certified medical tech)/Staff #83. Both Staff #249 and Staff #83 were working that night shift.

Staff #55 stated that after the incident, cares in pairs was implemented for Resident #1. Staff #55 stated that she informed the administrator via phone call of the incident on July 25 which was a Friday and she also spoke with the DON and she thinks that their Director of Rehab also informed the DON. Staff #4 was

the therapist whom Resident #1 informed of the incident on July 25. Staff #55 stated that after reporting the incident to the administrator and DON, she went and interviewed Resident #1 with the wound care nurse, but resident was eating lunch and had a visitor and wanted them to come back later. The second visit to Resident #1 was with the unit coordinator to assist with translation. Staff #55 stated that the resident did not say the way the therapist had reported it to her. Staff #55 stated that the nurse came in the room while Resident #1 was half dress, and the nurse was trying to wake Resident #1 up by rubbing on Resident #1's chest because the nurse was concern that Resident #1 was altered and the staff placed Resident #1 back

in bed. Staff #55 did not remember any other abuse incident, just this one for this year.An interview was conducted on August 12, 2025 at 11:17 AM in the 2200 nursing station with Staff #65. Staff #65 stated that as the unit coordinator, her responsibility includes setting up appointments and transportations, she speaks Spanish, she helps translates. She stated that she translated for one of the unit managers regarding an incident in July. She stated that her abuse training includes if she hears any allegation of abuse, she will report it to the administrator. She stated that 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.On August 12, 2025 at 11:30 AM, an exit interview was conducted with the administrator/Staff #28 and the DON/Staff #133 in

the conference room. At 11:52 AM, the DON stated that when the physical therapist note had come up, she and the administrator spoke with the Director of Rehab. The DON does not remember when they spoke with the Director of Rehab. The DON stated that she also spoke with Resident #1 and Resident #1 denied

the accusation. The DON stated that she had concerns with medication administration during the incident, and that is when the administrator reported the incident to the police, DHS (department of health services), which is in their 5-day report. The DON stated that 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. During the interview, the administrator stated that they verified the incident with Resident #1 and the family member and confirmed that nothing happened. The administrator stated that the physical therapy note was not reflecting the reality of what Resident #1 stated once Resident #1 and the family member were interviewed.A review of facility's policy titled, 003 - Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, in effect date of January 1, 2024 revealed Residents have the right to be free from abuse. (8) Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. (9) Investigate and report any allegations within timeframes required by federal requirements. (10) Protect residents from any further harm during investigations.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Haven Health Sky Harbor, LLC

1880 East Van Buren Street Phoenix, AZ 85006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

wound care nurse, but resident was eating lunch and had a visitor and wanted them to come back later. The second visit to Resident #1 was with the unit coordinator to assist with translation. Staff #55 stated that the resident did not say the way the therapist had reported it to her. Staff #55 stated that the nurse came in the room while Resident #1 was half dress, and the nurse was trying to wake Resident #1 up by rubbing on Resident #1's chest because the nurse was concern that Resident #1 was altered and the staff placed Resident #1 back in bed. Staff #55 did not remember any other abuse incident, just this one for this year.An

interview was conducted on August 12, 2025 at 11:17 AM in the 2200 nursing station with Staff #65. Staff #65 stated that as the unit coordinator, her responsibility includes setting up appointments and transportations, she speaks Spanish, she helps translates. She stated that she translated for one of the unit managers regarding an incident in July. She stated that her abuse training includes if she hears any allegation of abuse, she will report it to the administrator. She stated that 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.On August 12, 2025 at 11:30 AM, an exit interview was conducted with the administrator/Staff #28 and the DON/Staff #133 in the conference room. At 11:52 AM, the DON stated that when the physical therapist note had come up, she and the administrator spoke with the Director of Rehab. The DON does not remember when they spoke with the Director of Rehab. The DON stated that she also spoke with Resident #1 and Resident #1 denied the accusation. The DON stated that she had concerns with medication administration during the incident, and that is when the administrator reported the incident to the police, DHS (department of health services), which is in their 5-day report. The DON stated that 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.

During the interview, the administrator stated that they verified the incident with Resident #1 and the family member and confirmed that nothing happened. The administrator stated that the physical therapy note was not reflecting the reality of what Resident #1 stated once Resident #1 and the family member were interviewed.A review of facility's policy titled, 003 - Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, in effect date of January 1, 2024 revealed Residents have the right to be free from abuse. (8) Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. (9) Investigate and report any allegations within timeframes required by federal requirements. (10) Protect residents from any further harm during investigations.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Haven Health Sky Harbor, LLC

1880 East Van Buren Street Phoenix, AZ 85006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

second visit to Resident #1 was with the unit coordinator to assist with translation. Staff #55 stated that the resident did not say the way the therapist had reported it to her. Staff #55 stated that the nurse came in the room while Resident #1 was half dress, and the nurse was trying to wake Resident #1 up by rubbing on Resident #1's chest because the nurse was concern that Resident #1 was altered and the staff placed Resident #1 back in bed. Staff #55 did not remember any other abuse incident, just this one for this year.An

interview was conducted on August 12, 2025 at 11:17 AM in the 2200 nursing station with Staff #65. Staff #65 stated that as the unit coordinator, her responsibility includes setting up appointments and transportations, she speaks Spanish, she helps translates. She stated that she translated for one of the unit managers regarding an incident in July. She stated that her abuse training includes if she hears any allegation of abuse, she will report it to the administrator. She stated that 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.On August 12, 2025 at 11:30 AM, an exit interview was conducted with the administrator/Staff #28 and the DON/Staff #133 in the conference room. At 11:52 AM, the DON stated that when the physical therapist note had come up, she and the administrator spoke with the Director of Rehab. The DON does not remember when they spoke with the Director of Rehab. The DON stated that she also spoke with Resident #1 and Resident #1 denied the accusation. The DON stated that she had concerns with medication administration during the incident, and that is when the administrator reported the incident to the police, DHS (department of health services), which is in their 5-day report. The DON stated that 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.

During the interview, the administrator stated that they verified the incident with Resident #1 and the family member and confirmed that nothing happened. The administrator stated that the physical therapy note was not reflecting the reality of what Resident #1 stated once Resident #1 and the family member were interviewed.A review of facility's policy titled, 003 - Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, in effect date of January 1, 2024 revealed Residents have the right to be free from abuse. (8) Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. (9) Investigate and report any allegations within timeframes required by federal requirements. (10) Protect residents from any further harm during investigations.

Event ID:

Facility ID:

If continuation sheet