Inspection Reports for
Haven Health Tucson

The complaint involved an allegation by Resident #1's family member that the resident was neglected on November 16, 2025, including being left in urine-soaked sheets, uncovered, with oxygen equipment improperly applied, and poor hygiene. The family member reported the concerns via email on November 17, 2025, but the facility failed to respond appropriately or notify state agencies. Interviews with staff confirmed neglect is considered abuse and should be reported immediately. The Director of Nursing admitted missing the neglect allegation in the email and did not notify authorities as required.

The facility failed to timely report an allegation of neglect for Resident #1 to appropriate state agencies and failed to investigate the allegation. The Director of Nursing admitted missing the neglect allegation in an email and did not notify authorities as required by policy. The resident was found in poor condition as reported by family, and staff interviews confirmed the facility's deficient response.

The facility failed to ensure that physician-ordered intravenous sodium chloride solution was administered as ordered and did not notify the physician of a critical potassium laboratory result for resident #22, resulting in the resident not receiving appropriate treatment and subsequent decline.

Recertification survey combined with complaint investigation citing 7 deficiencies related to medication disposal, restraint monitoring, hearing assistance, care planning, medication administration, infection control, and dietary services.

The facility failed to ensure that resident #46 received adequate assistance to maintain hearing ability, including lack of hearing aids on the resident's inventory and care plan, insufficient communication accommodations, and inadequate documentation of hearing aid use. The resident expressed frustration with communication difficulties, and staff acknowledged gaps in communication support.

The visit was complaint-related, triggered by concerns about physical restraint monitoring, medication administration errors, hearing aid assistance, discharge procedures, weight monitoring, and infection control practices.

The facility was found deficient in monitoring and evaluation of physical restraints, medication administration practices including improper handling and disposal of medications, failure to assist a resident with hearing aids, discharging a resident with an unnecessary PICC line, failure to weigh a resident on admission, and inadequate infection control practices during medication administration. These deficiencies posed risks of psychosocial harm, medication contamination, ineffective communication, infection, and nutritional issues.

An onsite complaint survey citing 2 deficiencies related to medical records documentation and care planning for fall prevention.

The facility failed to ensure accurate documentation of fall risk assessments for resident #1, resulting in an inaccurate assessment of the resident's fall history. Additionally, the facility did not have physician orders in place for fall mats used as fall preventative measures, although the mats were present in the resident's room.

Recertification survey combined with complaint investigation citing 8 deficiencies related to medication availability, antibiotic stewardship, continence care, pharmacy services, food accommodations, infection control, and care planning.

Recertification survey for Life Safety Code 2012 citing 1 deficiency related to maintenance of corridor doors.

The facility failed to provide appropriate care for a resident with an indwelling catheter, including inadequate documentation and monitoring of bladder scans and catheter care, which posed risks of urinary tract infections and discomfort. Additionally, the facility failed to accommodate dietary preferences and allergies for two residents, resulting in residents not receiving meals that met their needs and preferences.

The facility was found deficient in providing appropriate catheter care and continence management for one resident, ensuring timely availability and administration of medications for another resident, accommodating dietary preferences and allergies for two residents, and implementing an effective antibiotic stewardship program. Deficiencies included lack of documentation, failure to notify physicians, and failure to follow facility policies and protocols.

The complaint investigation focused on issues including failure to provide written notification of hospital transfers, improper medication administration, incomplete death documentation, inadequate infection control signage, and failure to notify families of COVID-19 cases. The findings substantiated these concerns with minimal harm or potential for actual harm.

The facility failed to provide timely written notification to residents and their representatives about hospital transfers, administered opioid pain medication outside ordered parameters, did not maintain complete and accurate clinical records regarding a resident's death, lacked proper infection prevention signage at facility entrances, and failed to notify residents and families timely about a new COVID-19 positive case.