Haven Of Tucson
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Resident #1. The DON noted that when the family member saw the bill for the resident's care he got upset and voiced concerns regarding Resident #1's care. The DON stated that if any family member alleged neglect, the facility would immediately report the allegation to all appropriate state agencies including police and suspend any identified staff members involved, during the investigation. The DON reviewed her emails from November 17, 2025 from the family member of Resident #1 and discovered that the family member alleged that Resident #1 was abused and neglected. The DON admitted that she missed this part of the email when she initially read it. The DON denied contacting the police and state agency but she confirmed that if she saw the allegation, she would have notified the state agency and police. Review of the Policy and Procedure titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, effective January 1, 2024, revealed that residents have the right to be free from neglect. The policy goes on to reveal that if neglect is reported then the facility would investigate and report any allegations within timeframes required by federal requirements.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/01/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Haven of Tucson
3705 North Swan Road Tucson, AZ 85718
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0610
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure
an allegation of neglect for 1 (Resident #1) out of 5 residents was investigated. The deficient practice could result in further neglect of residents and appropriate corrective actions not being taken. Findings include: Resident # 1 was re-admitted on [DATE REDACTED] with diagnoses that included metabolic encephalopathy, intracerebral hemorrhage, hemiplegia and hemiparesis following cerebral infarct affecting left non-dominant side.Review of the quarterly Minimum Data Set (MDS) dated [DATE REDACTED], revealed that the Brief Interview for Mental Status (BIMS) assessment was not completed due to Resident #1 being rarely or never understood.
The MDS documented his cognitive skills for daily decision making as severely impaired. The MDS also revealed that the resident was dependent on staff for toileting hygiene, bathing, upper and lower body dressing, and personal hygiene.A comprehensive care plan revised on November 11, 2025 revealed that
the resident had functional self-care deficits and functional mobility limitations. Interventions indicated that
the resident requiring total assistance with bed mobility, toileting hygiene, transferring with Hoyer lift, and to bathe.An email sent to the Director of Nursing (DON/Staff #118) dated November 17, 2025, revealed that Resident # 1's family member reported that the resident appeared to have not been changed in several hours. Additionally, the resident's legs hung off the bed with no socks, the nasal canula was off his nose with no oxygen running, and mucus was all over his shirt and beard. The email alleged that this is abuse and neglect. An interview with Resident # 1's family member was conducted on December 1, 2025 at 11:22 a.m. The family member stated that during a visit on November 16, 2025, he witnessed his father laying in a low-lying bed with soaked sheets, and uncovered. The family member said he looked for the certified nursing assistant (CNA) assigned to Resident #1 but could not find him and addressed concerns with the nurse in charge. The family member stated that once the resident was cleaned up, he went home and emailed the facility his observations/concerns. The family member alleged that his dad was being neglected
the morning of November 16, 2025. The family member noted that he has not received a response from the facility regarding his neglect allegation. An interview with a CNA (Staff #43) was conducted on December 1, 2025 at 3:23 p.m., stated that neglect is abuse. Per the CNA if a family member claimed that a resident was neglected, she would immediately report the allegation to the Administrator who would then conduct an investigation.An interview with a Registered Nurse (RN/Staff #165) was conducted on December 1, 2025 at 3:40 p.m. Staff #165 said that abuse could be neglect, physical and verbal. Staff #165 noted that the administrator and DON would conduct the investigation and the nurse would assist by conducting the resident's skin and neurological assessments. An interview with DON (Staff #118) was conducted on December 1, 2025 at 3:59 p.m. The DON said that if any family member raised concerns of neglect, the facility immediately reports the allegation to all appropriate state agencies including police. Furthermore,
the involved staff is suspended during the investigation. The DON reviewed her emails from November 17, 2025 and discovered an email that alleged abuse and neglect of Resident #1. The DON admitted that she missed this part of the email when she initially read it. The DON noted that had she seen the allegation, she would have initiated an investigation. Review of the Policy and Procedure titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, effective January 1, 2024, revealed that residents have the right to be free from neglect. The policy goes on to reveal that if neglect is reported
the facility would identify and investigate all possible incidents of neglect.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
HAVEN OF TUCSON in TUCSON, AZ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TUCSON, AZ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HAVEN OF TUCSON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.