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 treatment and laboratory tests were administered and reported as ordered for resident #22, resulting in the resident not receiving appropriate treatment and a critical lab value not being communicated to the physician, contributing to the resident's decline and death.

The complaint investigation focused on resident #46's hearing impairment and the facility's failure to provide adequate assistance with hearing aids and communication. The resident expressed anxiety and frustration over malfunctioning hearing aids and difficulty communicating with staff. Staff interviews confirmed inconsistent use of communication aids such as writing messages. The complaint was substantiated with findings of deficient care planning and communication support.

The facility failed to ensure resident #46 received proper assistance with hearing aids and communication. Observations, clinical record reviews, and interviews revealed lack of hearing aid use, inadequate care planning for hearing needs, and insufficient communication accommodations.

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.

The complaint investigation found that the fall risk evaluation did not document a recent fall that resulted in hospital transfer, and that fall mats were used without physician orders. Interviews with staff including CNA, MDS nurse, LPNs, and the Director of Nursing confirmed these findings and noted potential risks of inaccurate documentation and miscommunication.

The facility failed to accurately document a resident's fall risk assessment, omitting a recent fall from the evaluation, and failed to have physician orders in place for fall mats used as fall preventative measures. These deficiencies could result in inaccurate medical records and potential miscommunication among staff.

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.

The investigation was complaint-driven, focusing on allegations of inadequate continence care, medication availability issues, failure to accommodate dietary needs, and insufficient infection control practices. The report documents interviews, clinical record reviews, and policy assessments supporting these findings.

The facility was found deficient in providing appropriate catheter care and continence management for one resident, ensuring timely availability 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 inadequate monitoring and follow-up.

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 visit was complaint-related, investigating issues including failure to notify residents and representatives about hospital transfers, medication administration errors, incomplete death documentation, infection control signage deficiencies, and COVID-19 notification failures. Substantiation status is not explicitly stated.

The facility was found deficient in timely written notification of hospital transfers to residents and their representatives, administration of unnecessary medications outside ordered parameters, incomplete and inaccurate clinical documentation of a resident's death, lack of posted infection control signage at facility entrances, and failure to notify residents and families of new COVID-19 cases within the required timeframe.