Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Of Tucson during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy and pneumonitis was using bilateral soft mitts as restraints, but the facility failed to consistently monitor and document their use. Despite staff training, interviews revealed that required checks and documentation were often missed, and the resident's task charts were incomplete. The facility's policy mandates repositioning and exercise opportunities every two hours, which were not consistently provided, posing a risk of skin breakdown.
An LPN failed to follow professional standards during medication administration by handling a Mirapex tablet with ungloved hands, splitting it without a pill cutter, and improperly disposing of a refused medication. The DON confirmed these actions did not meet facility expectations or comply with regulations.
A resident was discharged from a facility with a PICC line still in place, despite the completion of IV antibiotics. The PICC line was not removed until the following day, after the resident had been transferred to an assisted living facility. Facility staff acknowledged that the PICC line should have been removed prior to discharge, as per facility policy.
A resident with complex medical needs was not weighed upon admission, contrary to physician orders and facility policy. The resident, who had conditions such as quadriplegia and malnutrition, was not weighed until several days later, impacting the assessment of their nutritional needs. Facility staff confirmed the oversight, which violated the facility's Nutrition Management Program and Weight Assessment policy.
An LPN improperly disposed of medications by saving half of a Mirapex tablet in an unlabeled cup for later use and discarding a Geri-Kot in a resident's trashcan. The DON confirmed these actions did not align with facility policies, which require proper disposal according to state and federal guidelines.
An LPN was observed dispensing and splitting a Mirapex tablet with ungloved hands and retrieving a refused medication from a cup without gloves, contrary to facility policy. The DON confirmed these actions did not meet expectations and posed a contamination risk.
A resident with minimal hearing difficulty did not receive adequate assistance to maintain hearing ability, as the facility failed to document and plan for the use of hearing aids. Despite being cognitively intact, the resident experienced anxiety and frustration due to malfunctioning hearing aids and ineffective communication with staff. Observations and interviews revealed a lack of assistive devices and inconsistent use of communication aids, contrary to facility policies.
A resident with multiple diagnoses experienced a fall resulting in injuries, but the fall risk evaluation inaccurately recorded no falls in the past 90 days. Staff interviews revealed the fall should have been documented, affecting the scoring and potentially the implementation of services. The facility's policy requires accurate fall risk evaluations, which was not followed, leading to potential miscommunication.
A resident with multiple diagnoses and a history of falls was observed to have fall mats in place without a physician order, as required by facility policy. Staff interviews confirmed the need for such orders, but a review of the medical record showed none were present, indicating a deficiency in maintaining professional standards of care.
Failure to Monitor and Document Restraint Use
Penalty
Summary
The facility failed to ensure proper monitoring and evaluation of physical restraints for a resident, leading to a deficiency in care. The resident, who was admitted with metabolic encephalopathy and pneumonitis, was using bilateral soft mitts as a form of physical restraint. The care plan required that the mitts be released every two hours for ten to fifteen minutes, and that staff conduct frequent checks for safety and positioning, as well as monitor for any skin breakdown. However, observations and interviews revealed that these protocols were not consistently followed. On the day of the survey, the resident was observed with the mitts on, and the power of attorney (POA) expressed concerns that the facility had not adhered to the agreed-upon restraint protocols. Interviews with staff, including a CNA, a Care Coordinator, and an LPN, confirmed that while they were trained on the proper use of restraints, there were instances where documentation and monitoring were not completed as required. The LPN admitted that charting checks were sometimes missed, and the Director of Nursing acknowledged that the task charts for the resident were not completed accurately for most of the previous 14 days. The facility's policy on the use of restraints mandates that residents should be repositioned every two hours and given opportunities for motion and exercise. The failure to adhere to these guidelines, as evidenced by incomplete documentation and monitoring, did not meet the facility's professional standards and posed a risk of skin breakdown for the resident. The deficiency was identified through a combination of observations, record reviews, and interviews with staff and the resident's POA.
Failure to Adhere to Medication Administration Standards
Penalty
Summary
The facility failed to ensure professional standards were met during medication administration, as observed during a medication administration session with an LPN. The LPN was seen dispensing a Mirapex tablet into his ungloved hand, splitting it without using a pill cutter, and placing the residual half into an unlabeled medication cup for later use. Additionally, the LPN retrieved a refused medication from a cup with ungloved hands and disposed of it in the resident's room trash instead of using a sharps container. These actions were contrary to the facility's policy, which requires the use of gloves and a pill cutter for splitting medications and proper disposal of unused medications. Interviews with the LPN and the DON confirmed that these practices did not meet the facility's expectations or comply with state guidelines and regulations. The LPN admitted to not knowing the policy regarding the disposal of residual medication and acknowledged the failure to use gloves and a pill cutter. The DON emphasized that the correct procedure involves wearing gloves, using a pill cutter, and disposing of residual medication rather than saving it. The facility's policy review indicated that medications should not be touched with bare hands and should be disposed of according to state and federal guidelines.
Resident Discharged with Unnecessary PICC Line
Penalty
Summary
The facility failed to ensure that a resident was not discharged with an unnecessary device, specifically a PICC line, which could result in infection and increased risks of death. The resident was admitted with diagnoses including a urinary tract infection and was on antibiotic therapy with Meropenem, which was discontinued on January 19, 2024. Despite the discontinuation of the antibiotics, the PICC line was not removed, and the resident was discharged to an assisted living facility on February 6, 2024, with the PICC line still in place. The clinical records indicated that the orders to flush and monitor the PICC line were discontinued on January 30, 2024, and the last dressing change was noted on January 25, 2024. However, the resident retained the PICC line until February 7, 2024, when it was removed by a nurse from the skilled nursing facility after the resident had already been discharged. Interviews with staff revealed that the PICC line should have been removed after the completion of IV antibiotics, and it was acknowledged that the resident should not have been discharged with the PICC line. The facility's policy on intravenous therapy emphasized the importance of preventing complications associated with intravenous therapy, including catheter-related infections. The policy required regular monitoring and maintenance of the PICC line, which was not adhered to in this case. The Director of Nursing confirmed that the resident should not have been discharged with a PICC line unless they were continuing IV antibiotics at home, which was not the case for this resident.
Failure to Weigh Resident on Admission
Penalty
Summary
The facility failed to weigh a resident upon admission, which is a critical step in assessing and managing the nutritional and hydration needs of residents. The resident, who was admitted with diagnoses including quadriplegia, protein-calorie malnutrition, a feeding tube, and difficulty swallowing, was not weighed until several days after admission. This oversight was contrary to the physician's order and the facility's policy, which mandates that residents be weighed within 24 hours of admission. The resident's care plan emphasized the importance of monitoring weight to prevent significant weight changes, yet the initial weight was not recorded until December 3, 2024, despite the admission occurring earlier. Interviews with facility staff, including a CNA, the Dietary Manager, the Executive Director, and the Director of Nursing, confirmed the lapse in protocol. The CNA acknowledged the responsibility to obtain weights upon admission, while the Dietary Manager and DON verified that the initial weight was not recorded as required. The facility's Nutrition Management Program and Weight Assessment and Intervention policy both stipulate that residents be weighed upon admission and at specified intervals, highlighting the importance of this practice in managing residents' health. The failure to weigh the resident as per protocol and physician orders represents a significant deficiency in the facility's care processes.
Improper Medication Disposal Practices
Penalty
Summary
The facility failed to ensure proper disposal of medications according to accepted professional standards, as observed during a medication administration session. An LPN was seen splitting a Mirapex tablet and placing one half into an unlabeled medication cup for later use, which was then stored in the medication cart. Additionally, the LPN disposed of a Geri-Kot medication in a resident's room trashcan after the resident refused it. These actions were not in line with the facility's expectations or policies regarding medication disposal. Interviews with the LPN and the Director of Nursing (DON) revealed a lack of adherence to the facility's medication disposal policy. The LPN admitted uncertainty about the policy and acknowledged that the actions taken did not meet facility expectations. The DON confirmed that the facility's process should involve disposing of unused medication halves and not saving them for later use, as well as ensuring medications are not disposed of in the trash. The facility policy requires that non-controlled and Schedule V controlled substances be disposed of according to state and federal guidelines, which was not followed in these instances.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, as observed during a survey. An LPN was seen dispensing a Mirapex tablet into his ungloved hand, splitting the medication with ungloved hands, and then placing it into a medication cup. Additionally, the LPN retrieved a medication that a resident refused from a medication cup with ungloved hands and returned the cup to the resident with other medications for administration. These actions were contrary to the facility's policy, which requires that medications not be touched with hands and that gloves be worn when handling medications. Interviews with the LPN and the Director of Nursing confirmed that the observed practices did not meet the facility's expectations and posed a risk of contamination. The LPN acknowledged that he should have asked the resident to retrieve the refused medication and dispose of it properly. The Director of Nursing stated that the correct procedure for cutting medication involves wearing gloves and using a pill cutter. The facility's policy review further supported that medications should not be handled with bare hands, highlighting a clear deviation from established protocols.
Failure to Assist Resident with Hearing Needs
Penalty
Summary
The facility failed to ensure that a resident received adequate assistance to maintain hearing ability, which could lead to ineffective communication. The resident, who was admitted with a right pelvic fracture, atrial fibrillation, and other conditions, was cognitively intact but had minimal difficulty hearing. Despite this, the resident's inventory did not list hearing aids, and the care plan lacked focus, goals, or interventions for hearing. The Minimum Data Set (MDS) did not indicate the use of hearing aids, and there was no information in the clinical record about the resident's hearing aid usage or assistance needed. Observations revealed that the resident had a hearing aid for the left ear, but no other assistive devices were present. The resident expressed anxiety and frustration over the malfunctioning hearing aid and difficulty communicating with staff. Interviews with staff indicated that while they attempted to accommodate the resident by speaking clearly, they did not consistently use writing materials to aid communication. The resident confirmed that staff did not write messages down, which would have been helpful. Interviews with facility staff, including the Social Services Director and MDS Coordinator, highlighted a lack of documentation and planning for the resident's hearing needs. The Director of Nursing acknowledged that the hearing aid should have been included in the inventory, MDS, and care plan. The facility's policies on accommodating needs and caring for hearing-impaired residents were not effectively implemented, leading to the deficiency in providing adequate hearing assistance to the resident.
Inaccurate Fall Risk Assessment Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident regarding fall risk assessments. The resident, who had a recent admission with multiple diagnoses including Alzheimer's disease and major depressive disorder, experienced a fall resulting in injuries such as a laceration and bruising. Despite this incident, the fall risk evaluation inaccurately recorded that the resident had no falls in the past 90 days, contradicting the facility's progress notes and hospital discharge documentation. Interviews with staff revealed that the fall should have been documented in the fall risk evaluation, which would have affected the scoring and potentially the implementation of services. The MDS nurse acknowledged the oversight, and the DON confirmed that the expectation was for an accurate fall risk evaluation to be completed. The facility's Fall Prevention Program policy requires a thorough review of history and fall risk evaluation for new admissions, but this was not adhered to in this case, leading to inaccurate documentation and potential miscommunication among staff.
Lack of Physician Orders for Fall Mats
Penalty
Summary
The facility failed to ensure that physician orders were in place for fall preventative measures, specifically regarding the use of fall mats for a resident. The resident, who had a recent admission with multiple diagnoses including metabolic encephalopathy, Alzheimer's disease, and major depressive disorder, was identified as being at risk for falls. The resident's care plan included interventions such as bilateral landing strips placed on both sides of the bed. However, a review of the resident's medical records revealed no evidence of a current physician order for these fall mats. Interviews with staff members, including two LPNs and the Director of Nursing, confirmed that orders are required for the implementation of fall mats. Despite the care plan indicating the need for landing strips, the absence of a physician order was noted. Observations confirmed the presence of fall mats next to the resident's bedside, but the lack of a formal order highlighted a deficiency in maintaining professional standards of quality care. The facility's policy requires physician orders to be maintained in accordance with OBRA regulations, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tucson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Center At Tucson | 1.1 mi | — | 0 | 0 |
| Villa Maria Post Acute And Rehabilitation | 1.7 mi | — | 5 | 0 |
| Foothills Rehabilitation Center | 1.8 mi | — | 12 | 0 |
| Handmaker Home For The Aging | 1.8 mi | — | 12 | 1 |
| Santa Rosa Care Center | 2.1 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.