Haven of Tucson

In the surveyor’s words

From the most serious findings on record at Haven of Tucson, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 12, 2025

  Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure physician-ordered laboratory and intravenous treatment was administered as ordered; and failed to ensure the physician was notified of a critical laboratory result for 1 of 3 sampled residents (#22). This deficient practice resulted in the resident not receiving the prescribed and appropriate treatment needed, resulting in further decline.Findings include:Resident #22 was admitted on [DATE], with diagnoses of malignant neoplasm of the upper lobe right bronchus or lung, malignant pleural effusion, and pneumonia. […]

• Actual harm, isolatedF690Mar 2, 2023

  Based on resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident (#127) received care and services to restore and/or maintain continence. The sample size was 18. The deficient practice could adversely impact the resident's dignity and result in bowel and bladder continence not being maintained. Findings include: Resident #127 admitted to the facility on [DATE] with diagnoses including fracture of sacrum, subsequent encounter for fracture with routine healing, intervertebral disc degeneration, lumbar region and retention of urine. An indwelling catheter care plan dated 02/14/23 related to acute neurogenic bladder had a goal to be/remain free from catheter-related trauma. […]

• No harm, potential for more than minimal, patternF558Apr 21, 2026

  Based on facility observations, staff interviews, record review, and review of facility policies, the facility failed to ensure that one shower room was maintained in a clean and safe condition in accordance with professional standards of practice. This deficient practice had the potential to affect residents by failing to provide a clean, safe, and homelike environment. The sample was 1 of 1 and the census was 121.Findings Include:Resident #15 was admitted to the facility on [DATE], with diagnoses including heart failure, hypertension, Type II Diabetes Mellitus, respiratory failure, and other comorbid conditions.Resident #15 was one of the residents on the Heritage 200 hallway who had recently received a tracheostomy due to respiratory failure. […]

• No harm, potential for more than minimal, patternF880Mar 2, 2023

  Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to conduct an ongoing review for antibiotic stewardship as required by Center for Medicare and Medicaid Services (CMS) guidelines, and failed to review clinical signs and symptoms and laboratory reports to determine if antibiotics are indicated. The deficient practice could have the potential for residents to have adverse effects due to the lack of protocols and monitoring. Findings include: On February 27, 2023 at 8:00 a.m. the survey team entered the facility. At 8:36 a.m., an entrance conference was conducted with the facility administrator (staff # 124). During the conference, staff #124 stated he has a full-time infection preventionist (IP), staff #100. […]

• No harm, potential for more than minimal, patternF880Feb 18, 2022

  Based on observations, staff interviews, and policy reviews, the facility failed to ensure that signage was posted at facility entrances alerting visitors when not to enter the facility and appropriate infection prevention and control actions to take while in the facility. The deficient practice may result in visitors not being informed of infection prevention and control actions to take while in the facility. Findings include: -An observation was conducted on February 15, 2022 at 7:55 a.m., upon entry to the facility, no signage was posted on the door alerting visitors of appropriate infection prevention and control actions to take while in the facility. […]