Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 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.
Dirty Shower Room HVAC Vent: A resident with HF, HTN, DM2, respiratory failure, and a recent tracheostomy reported that the shower room vent used for showers was filthy and full of dust for about two months. Surveyors observed the HVAC exhaust grille covered with dust on multiple occasions, and staff gave inconsistent accounts of cleaning frequency while the maintenance log showed the vent grilles had not been cleaned since late February.
Failure to Refer Resident for Level II PASRR: A resident admitted with bipolar disorder, schizoaffective disorder, and moderate cognitive impairment had a level I PASRR completed that did not identify SMI or psychotropic meds, and no level II referral was found in the chart. Facility staff later acknowledged the resident had two SMI diagnoses and could not explain why the resident was not referred, despite policy stating that residents with mental illness or ID require a level II referral.
A resident with moderate cognitive impairment and multiple medical diagnoses developed a large bruise/hematoma on the upper right arm that was noted on shower sheets and observed by staff, but it was not clearly documented, monitored, or linked to a provider notification in the clinical record. Staff interviews confirmed the bruise was seen, appeared to be healing, and had no monitoring plan beyond routine skin checks, while the DON acknowledged the record lacked clear documentation of the injury.
The facility failed to ensure a CNA maintained CPR and First Aid certification when the CNA’s signed job description listed CPR as a minimum requirement, and failed to follow its RN job description requiring an active, non-probationary RN license. Review of personnel files showed one CNA had no CPR/First Aid certification on file and an RN had a probationary license despite the signed job description requiring non-probationary status. Interviews with the HR Director and DON confirmed the mismatches between the job descriptions and the staff credentials.
Failure to report an allegation of neglect. A resident with severe cognitive impairment and total care needs was found by a family member lying uncovered in urine-soaked sheets, with the family also reporting the resident had not been changed, had no socks, and had the NC off with no oxygen flowing. The family emailed the DON stating the situation was abuse and neglect, but the DON later said she missed that part of the email and did not report the allegation to the police or state agency.
Failure to Investigate Allegation of Neglect: A resident with severe cognitive impairment and total care needs was reported by family to have been left in soaked sheets, uncovered, without socks, with the nasal cannula off and mucus on his clothing and beard. The family alleged neglect, but the DON later stated she missed the neglect allegation in the email and did not initiate an investigation when the concern was first reported.
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.
Dirty Shower Room HVAC Vent
Penalty
Summary
The facility failed to ensure that a shower room on the Heritage 200 hallway was maintained in a clean and safe condition. Resident #15, who had diagnoses including heart failure, hypertension, Type II diabetes mellitus, respiratory failure, and other comorbid conditions, and who had recently received a tracheostomy, reported that the vent in the shower room used for showers was filthy and full of dust. The resident stated that the condition had been present for approximately two months and that he had told CNAs multiple times, but no corrective action had been taken. Survey observations confirmed that the HVAC exhaust grille in the shower room ceiling was filthy and covered with dust on multiple occasions. A CNA observed that the vent was not clean and stated that maintenance should clean vent grilles routinely. The Maintenance Director stated that vent grilles were cleaned monthly and that the facility expected them to be kept clean at all times, but also acknowledged that the 30-day vent cleaning had not been entered into the maintenance reporting system. Review of the maintenance log showed that air filters, including HVAC vent grilles, had last been cleaned on February 25, 2026. The housekeeping manager stated that HVAC vents were cleaned weekly, and the Unit Manager stated that failure to clean the shower room vent grilles could compromise residents with respiratory conditions, including those with tracheostomies.
Failure to Refer Resident for Level II PASRR
Penalty
Summary
The facility failed to ensure one resident was referred for a level II PASRR after the resident was admitted with diagnoses that included metabolic encephalopathy, type 2 diabetes, bipolar disorder, and schizoaffective disorder. The quarterly MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and also documented bipolar disorder, schizoaffective disorder, and antidepressant use. The order summary showed Risperidone for bipolar disorder and unstable mood, as well as Trazodone for depression and inability to sleep. The resident’s level I PASRR, completed by Marketing/Admissions, indicated no serious mental illness or mental disorder and did not identify psychotropic medications or recommended services. When the clinical record was reviewed, there was no documentation of a referral for a level II PASRR on file. The DON stated the facility did not have the level II referral due to recent staff changes. During interviews, staff stated that residents with qualifying mental health diagnoses should be referred for a level II PASRR, and the Resident Relations Manager reviewed the chart and identified bipolar disorder and schizoaffective disorder as two SMI diagnoses. She was unable to determine why the resident was not referred for a level II PASRR even though he met the criteria. The Admissions staff member who completed the initial PASRR stated he reviewed the hospital chart and entered the form into the state portal, but he was not sure when a resident needed a level II referral and did not know why this resident was not triggered for one. The facility policy stated that if a resident has a diagnosis of mental illness or intellectual disability, a level II referral must be submitted by the facility.
Failure to Monitor and Document a Large Right Arm Bruise
Penalty
Summary
The facility failed to ensure that Resident #4 was monitored and assessed for changes in condition after bruising was identified on the upper right arm. Resident #4 was admitted with diagnoses including metabolic encephalopathy, type 2 diabetes, dysphagia, and a renal and perinephric abscess. Her admission MDS showed a BIMS score of 08, indicating moderate cognitive impairment, and no history of falls prior to admission. A weekly skin check and wound assessment dated April 8, 2026 did not note any bruise on the upper right arm, but a shower sheet dated April 11, 2026 documented a bruise to the right upper arm. Resident #4 was later found on the floor in a prone position on April 16, 2026 and was assessed for injuries with none found, although an interdisciplinary team note from that date indicated she had hit her head and had a hematoma. Another shower sheet dated April 18, 2026 again documented a bruise to the right upper arm, and an observation on April 19, 2026 found a large dark purple area on the upper right arm. Interviews with CNA, LPN, RN, and the DON showed staff observed the bruise but did not have documentation of a monitoring plan, did not find documentation of the contusion in the clinical record, and did not see evidence that the provider was notified of the bruising. The RN described the bruise as a hematoma on the right upper bicep measuring approximately 7 to 8 cm by 4 cm and stated it appeared to have been present for about a week and was healing. The DON reviewed the record and confirmed there was no documentation regarding the bruising identified on the shower sheet and no clear monitoring related to the bruising.
Staff Competency and Certification Requirements Not Met
Penalty
Summary
The facility failed to ensure that one of two sampled CNAs, Staff #98, maintained current CPR and First Aid certification, even though the CNA job description signed by the staff member listed an active, class-instructed CPR certification as a minimum requirement. Review of Staff #98’s personnel file showed a hire date and signed job description, but no evidence that the CNA obtained or maintained CPR or First Aid certification. In contrast, review of another CNA’s file, Staff #46, showed evidence of current CPR and First Aid certification. The facility also failed to follow its own job description requirement for an RN, Staff #90, whose signed RN job description listed an active, non-probationary RN license as a minimum requirement. Review of Staff #90’s personnel file showed an active Arizona RN license with probationary status and an original issue date of February 17, 2021. The HR Director confirmed that Staff #90’s license was probationary and did not meet the minimum requirement stated in the signed job description. During interviews, the HR Director stated that Staff #98’s current signed job description required CPR certification, while an undated newer CNA job description listed CPR as a preferred skill, and Staff #98 had not signed that newer version. The DON stated that Staff #90’s probationary license did not match the minimum requirement on the RN job description and that Staff #98’s file contained no CPR/First Aid certification. Facility policies reviewed stated that nursing staff would have the appropriate skills and competency necessary to provide care, and that personnel would complete CPR/BLS training and maintain certification, including for key clinical staff and non-licensed personnel.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to follow its policy for reporting an allegation of neglect for one resident to all applicable state agencies. The resident was re-admitted with diagnoses including metabolic encephalopathy, intracerebral hemorrhage, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The quarterly MDS showed the BIMS was not completed because the resident rarely or never understood and had severely impaired cognitive skills for daily decision making. The MDS also documented dependence on staff for toileting hygiene, bathing, upper and lower body dressing, and personal hygiene, and the care plan identified functional self-care deficits and mobility limitations requiring total assistance with bed mobility, toileting hygiene, transferring with a Hoyer lift, and bathing. A family member emailed the DON expressing concern that the resident had not been changed in several hours and was observed with legs hanging off the bed, no socks, the nasal cannula off with no oxygen flowing, and mucus on the shirt and beard, stating this was abuse and neglect. The family member later reported seeing the resident lying uncovered in a low-lying bed with urine-soaked sheets and said he could not find the CNA assigned to the resident. Staff interviews showed they understood that neglect is abuse and that such allegations should be immediately reported to the Administrator and then to the appropriate authorities. The DON acknowledged that she reviewed the email but missed the allegation of abuse and neglect, and she confirmed that she did not contact the police or state agency after reading it.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to ensure that an allegation of neglect involving one resident was investigated. The resident was re-admitted with diagnoses including metabolic encephalopathy, intracerebral hemorrhage, and hemiplegia and hemiparesis following cerebral infarct affecting the left non-dominant side. The quarterly MDS showed the resident was rarely or never understood, had severely impaired cognitive skills for daily decision making, and was dependent on staff for toileting hygiene, bathing, dressing, and personal hygiene. The care plan identified functional self-care deficits and mobility limitations, with interventions for total assistance with bed mobility, toileting hygiene, transfers with a Hoyer lift, and bathing. An email to the DON reported that the resident’s family member said the resident appeared not to have been changed in several hours, had legs hanging off the bed with no socks, had the nasal cannula off with no oxygen running, and had mucus on his shirt and beard, and the email alleged abuse and neglect. The family member later stated he saw the resident lying in a low-lying bed with soaked sheets and uncovered, could not find the CNA assigned to the resident, and raised concerns with the nurse in charge before emailing the facility. Staff interviews indicated that allegations of neglect should be reported immediately and investigated by the Administrator and DON, but the DON stated she missed the neglect allegation in the email when she first read it and therefore did not initiate an investigation at that time.
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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Illustrative
What surveyors actually found near you
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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 | ★★★★★ | 26 | 0 |
| Handmaker Home For The Aging | 1.8 mi | ★★★★★ | 12 | 1 |
| Santa Rosa Care Center | 2.1 mi | ★★★★★ | 20 | 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 July 2026) and official state health department websites.