Haven of Saguaro Valley: Quality of Care Deficiency - AZ
The drug at the center of the findings is Midodrine, a medication that raises blood pressure and carries a physician-set ceiling for when it can safely be administered. On December 10, the medication administration record showed Midodrine given at 2:00 p.m. with a systolic blood pressure reading of 150. A separate progress note, reviewed during the inspection, said a nurse had held it because the reading was above parameters. On December 21, the same pattern: the MAR showed the drug administered at 2:00 p.m., but a progress note recorded that the nurse withheld it because the systolic reading exceeded 140.
The facility's Director of Nursing offered an explanation. She said nurses had likely removed the medication from its packaging in preparation for giving it, then checked the blood pressure, found it too high, and set the drug aside. They added a progress note after the fact and disposed of the medication. Nobody updated the MAR.
That left two entries in the official record showing a drug given that wasn't.
December 12 told a different story. The MAR showed Midodrine administered at 10:00 p.m. No follow-up medication note existed in the progress notes to indicate the blood pressure had been checked first. The Director of Nursing said the absence of that note meant the nurse gave the medication without verifying the reading, outside the physician's order. She described the consequence plainly: giving Midodrine outside parameters causes uncontrolled blood pressure.
Three dates. Two doses recorded as given that were held. One dose given that shouldn't have been. The Director of Nursing identified all of it herself during the inspection review.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Haven of Saguaro Valley from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
HAVEN OF SAGUARO VALLEY in TUCSON, AZ was cited for violations during a health inspection on December 23, 2025.
On December 10, the medication administration record showed Midodrine given at 2:00 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.