PHOENIX — “Baby's turning blue! Baby's turning blue!” 

A frantic 911 call came from a Phoenix Hacienda Healthcare facility in December as a patient reliant on around-the-clock care gave birth. 

"We had no idea this patient was pregnant," the caller told the dispatcher. 

RELATED: Documents: Incapacitated Hacienda patient who gave birth was repeatedly raped, possibly pregnant before

RELATED: 'Baby's not breathing, baby is blue!': 911 call from birth at Hacienda Healthcare released

Since then, former nurse Nathan Sutherland has been arrested, accused of raping the incapacitated patient. He pleaded not guilty to the charges.

The case brought to light several problems at Hacienda Healthcare over the past few months that go deeper and started well before the fateful 911 call. 

The privately-owned intermediate care facility was unlicensed by the state for more than 20 years before the surprise birth. Lawmakers had previously approved an exemption for privately run intermediate care facilities like Hacienda. 

In April, lawmakers reversed course, and Gov. Ducey signed legislation requiring state licensing and inspections for such facilities. The Arizona Department of Health Services recently approved a license for Hacienda Healthcare valid for 11 months.

RELATED: Arizona licenses center where incapacitated woman was raped

The facility also recently handed over its financial documents to the state after a lawsuit alleging they overcharged Arizona approximately $3 million.

Shortly after the announcement of the incapacitated woman giving birth, the former Hacienda CEO, Bill Timmons, resigned.

The governor would call out Hacienda leadership in series of harsh tweets in late January, tweeting in part, “My confidence level in that institution and its leadership is zero.”

“We want to see accountability for senior management. I want to see termination of the board.” Gov. Doug Ducey said. 

Former Maricopa County Attorney Rick Romley was hired to investigate what went wrong at the facility, but less than two months later, Romley was out—along with other members of the board and management.

“I do not believe that I am able to continue my work due to several issues involving certain members of Hacienda's board of directors,” Romley said in a statement.

RELATED: Ex-Hacienda CEO rips board's refusal to change after baby born to incapacitated patient

Since March, Perry Petrilli has taken over as the acting CEO.

Next month, the state’s medical board is expected to consider dismissing accusations of wrongdoing against the victim’s primary care physician.

RELATED: Doctor suspended because sex assault victim ‘endangered’ under care, letter says

12 News has asked the medical board whether new allegations laid out in a notice of claim, including allegations that staff at Hacienda missed 83 opportunities to diagnose the pregnancy, could impact their decision.

Medical board director Patricia McSorley replied, “Agency staff is not permitted to discuss complaints or investigations with the public."