Sandstone of Tucson Rehab Centre

Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of 1 resident (#1) to be free from verbal abuse by staff. The deficient practice could result in further abuse of residents and appropriate action not taken.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to follow 1 resident (#1) care plan during a behavioral episode. The deficient practice could place the residents' safety at risk.

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure an allegation of resident-to-resident abuse was reported to the applicable and required state agencies within 2 hours, for two of four sampled residents (#50 and #40). The deficient practice could result in an allegation of abuse not being reported and investigated in a timely manner, and could result in continued harm to residents.

Inspectors wroteBased on observation, interviews, and review of facility policy and procedure, the facility failed to ensure food was stored and prepared under sanitary conditions. The deficient practice could lead to pests in the kitchen and/or spread of infection to residents.

Inspectors wroteBased on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for one of four sampled residents (#20) regarding a fall. The deficient practice could result in care team members not being fully aware of a resident's condition and could cause missed care and treatment.

Inspectors wroteBased on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of two of four sampled residents (Residents #16, #45) to be free from abuse by another resident (#26 and #121). The universe was 117. The deficient practice could lead to additional resident-to-resident altercations, creating an unsafe environment. Findings Include: -Regarding Resident #45 and Resident #121 A facility-reported incident form dated March 31, 2026, revealed that Resident #121 stated that she overheard Resident #45 speaking to someone on the phone and was speaking negatively of the facility, and called Resident #121 a bad name. [...]

Inspectors wroteBased on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure an allegation of misappropriation was reported to mandated entities and within the required timeframe for 1 of 24 sampled residents (#42). The deficient practice could lead to allegations of misappropriation not being investigated thoroughly and timely.

Inspectors wroteBased on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure 1 of 24 sampled residents (#118) was protected from a preventable accident, related to a fall from the bed during brief change. The deficient practice could lead to physical injury of a resident.-

Inspectors wroteBased on review of the clinical record, interviews, and review of the facility's policies and procedures, the facility failed to protect the rights of one resident (#6) to be free from abuse from another resident (#9). The deficient practice could lead to sustaining injuries.

Inspectors wroteThe facility failed to ensure a signed consent was obtained before starting a new psychotropic medication for one resident, #4. The deficient practice could lead to a resident's responsible party not being informed of the risk and benefits of a resident's medications.

Inspectors wroteThe facility failed to ensure an allegation of abuse for one resident (#4) was reported to the State Agency (SA) within the timeframe established by regulations. The deficient practice could lead to continued abuse of residents.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect one resident (#511) rights in a manner that promotes enhancement of the resident's quality of life by having her own cell phone to access persons and services outside the facility. The deficient practice could lead to residents' rights being violated.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of one resident (#911) to be free from physical abuse by another resident. The deficient practice could result in further abuse of residents and appropriate action not taken.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#333) to be free from financial misappropriation/exploitation of resident property by another resident (#111). The deficient practice could result in further financial abuse of residents when appropriate actions are not taken.-Regarding Resident #111 (alleged perpetrator):Resident #111 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, obesity, and life management difficulty. Review of the care plan dated August 19, 2023, revealed that the resident has psychological aspects of chronic illness. The interventions included providing the Resident/Representative a list of community resources, and identifying the disease progression and when to notify the health care provider. [...]

Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to maintain documentation that an alleged violation related to the allegation of financial misappropriation of property for one resident (#333) by another resident (#111) was thoroughly investigated. The deficient practice could result in further financial abuse of residents when appropriate actions are not taken.-Regarding Resident #111 (alleged perpetrator):Resident #111 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, obesity, and life management difficulty. Review of the care plan dated August 19, 2023, revealed that the resident has psychological aspects of chronic illness. [...]

Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one resident (#191), which provides instructions to meet the resident's immediate needs. The deficient practice could result in resident's treatments and needs not appropriately addressed. Findings Include:Resident #191 was readmitted to the facility on [DATE], with diagnoses that included rhabdomyolysis (is a rare muscle injury where your muscles break down), adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit. A review of the Clinical admission Evaluation progress note dated August 3, 2024, revealed that the resident's admission mode was wheelchair. The Resident was alert and oriented times 3; alert (some forgetfulness). [...]

Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to review and revised the care plan for one resident (#191) after each fall incident. The deficient practice could place the resident at risk for more falls. Findings Include:Resident #191 was readmitted to the facility on [DATE], with diagnoses that included rhabdomyolysis (is a rare muscle injury where your muscles break down), adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit. A review of the Clinical admission Evaluation progress note dated August 3, 2024, revealed that the resident's admission mode was wheelchair. The Resident was alert and oriented times 3; alert (some forgetfulness). [...]

Inspectors wroteBased on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to identify elopement risks, and plan for effective supervision for resident one of three sampled residents (#888) related to risk factors for cognitively intact residents, and to ensure that one resident (#511) was supervised during activity sessions, and that activities were conducted safely. The deficient practice could result in avoidable accidents. Findings Include: [...]

Inspectors wroteBased on clinical record reviews, facility documentation, resident, family, and staff interviews, and policy review, the facility failed to protect the resident's (#10) rights to be free from abuse by another resident (#5). This deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on clinical record review, interviews, review of facility documentation and policies, the facility failed to protect The rights of one resident (# 07) to be free from verbal and physical abuse by another resident (#33). This deficient practice has the potential to violate the resident's right to safety and prevent further harm. The sample size was 5. The facility census was 122.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedure, the facility failed to protect the residents rights to be free from abuse by staff and other resident (#21, #9, #13, #2, #44, #10, #16, #40, #41, #42). The deficient practice could lead to further instances of abuse, thereby promoting an unsafe environment. Findings Include: -Regarding Resident #9 Resident #9 was admitted on [DATE] with diagnosis including paranoid schizophrenia, altered mental status, drug induced subacute dyskinesia, unspecified mental disorder due to known physiological condition, muscle weakness, lack of coordination, abnormalities of gait and mobility, cognitive communication deficit, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. [...]

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement policies and procedures for the documentation and reporting of alleged violations involving abuse for resident (#26). The deficient practice resulted in an allegation of abuse not being reported timely, and the potential for a resident not being protected from further abuse.-Regarding Resident #26Resident #26 was admitted on [DATE] and subsequently discharged on October 26, 2022 with diagnosis including morbid obesity with alveolar hypoventilation, chronic obstructive pulmonary disease, hypertension, type 2 diabetes mellitus with hyperglycemia, cellulitis, anemia, chronic pain syndrome, anxiety disorder, chronic and acute respiratory failure with hypoxia and unspecified schizoaffective disorder. [...]

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#200) was free from physical abuse from other residents (resident #300), and the facility failed to ensure that one resident #400 was free from abuse from staff. This deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to protect the rights of 2 of 8 sampled residents (Resident #2 and #6) to be free from abuse by another resident (Resident # 1 and #5). The deficient practice could result in other residents being abused. Regarding Resident #1 on Resident #2 Abuse:-Regarding Resident #1:Resident # 1 was admitted [DATE] with diagnoses that included, sepsis, bacteremia, urinary tract infection, Schizophrenia, restlessness and agitation. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) that was unable to be completed due to Resident # 1 not understanding the questions and having a severely impaired altered level of consciousness. The MDS also revealed a history of physical behavior directed toward others. [...]

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to protect the rights of on resident to be free from abuse (#2) by another resident (#4). The deficient practice could result in residents being physically and emotionally injured.-Regarding Resident #2Resident #2 was admitted to the facility March 27, 2025 with diagnosis including; cerebral palsy, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, unspecified dementia, moderate, with other behavioral disturbance, mild cognitive impairment of uncertain or unknown etiology, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, impulse disorder, unspecified. [...]

Inspectors wroteBased on interviews, record reviews, and observations, the facility failed to implement its policies for preventing and prohibiting abuse were implemented consistently by staff, resulting in a delay in reporting resident to resident abuse to the state agencies, physician, abuse coordinator and family.

Inspectors wroteBased on observation, interviews, review of documentation, and review of facility policies, the facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two residents (#2) and (#4). The deficient practice could lead to a failure of the facility to report allegations of abuse timely, and could lead to continued abuse for a resident.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to protect the rights of two residents (#69, #77) to be free from abuse by another resident (#81, #76). The deficient practice could result in other residents being abused.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an allegation of abuse was reported to the State Agency for one resident (#69). The deficient practice could result in abuse allegations not being reported.

Inspectors wroteBased on clinical record review, interviews, and review of facility policies, the facility failed to ensure residents (#1, #3, and #5) were free from abuse and neglect. The deficient practice could lead to physical and psychosocial harm to the residents.

Inspectors wroteBased on clinical record review, interviews, and policy and procedures, the facility failed to ensure that an allegation of verbal abuse and neglect, for one resident (#4), was reported to the State Survey Agency within the required timeframe.

Inspectors wroteBased on clinical review, staff interviews, and facility policy and procedures, the facility failed to ensure that behaviors were monitored and documented prior to medication administration for 2 out of 3 residents sampled (#1, #2). The deficient practice could result in residents being over-medicated.

Inspectors wroteBased on clinical record review, interviews, and policy review, the facility failed to ensure that one residents (#2) received treatment and care in accordance with professional standards of practice. The sample size was 3. This deficient practice could lead to residents not reciving the required care.

Inspectors wroteBased on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure residents were free from abuse. This deficient practice could result in psychosocial harm and further instances of abuse.

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#1) and (#2) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on clinical record review, interviews, and review of facility policies the facility failed to ensure an avoidable elopement was prevented. The deficient practice could result in residents finding themselves in unsafe situations in the community, unsupervised.

Inspectors wroteBased on review of resident council minutes, resident and staff interviews, and policy and procedures, the facility was unable to demonstrate that resident council meetings were held regularly and that their response and rationale to grievances and recommendations voiced during resident council meetings were addressed. The facility census was 154. The deficient practice could result in residents' concerns, views, grievances or recommendations not being considered or acted upon by facility staff.

Inspectors wroteBased on observations, staff interviews and facility policy, the facility failed to ensure that meals were provided to residents seated together at the same time. This practice could result in compromised dignity for the residents and a decrease of mental health.

Inspectors wroteBased on clinical review, staff interviews and facility policy and procedure, the facility failed to ensure that one resident (#401) was informed of their rights during their stay at the facility. The deficient practice could result in residents not understanding their rights and being able to advocate for themselves.

Inspectors wroteBased on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure one was resident (51) was not physically abused by another resident (154).

Inspectors wrote1. Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a referral for a PASARR (Preadmission Screening and Resident Review) level II determination was obtained timely for two residents (#56 and #38). The deficient practice could result in the resident not receiving the appropriate level of services.

Inspectors wroteBased on clinical record review, staff and resident interviews and policy review, the facility failed to ensure one resident (#114) or resident's representative was able to participate in the care planning process. The sample size was 31. The deficient practice could result in residents and representatives not participating in and understanding their plan of care.

Inspectors wroteBased on review of clinical records and policy, observations, and staff interviews the facility failed to ensure that at least one medication was not administered as ordered for three residents # 448, # 38, and # 99 out of five residents observed. The deficient practice of incorrect medication administration does not align with accepted professional standards of practice and may result in undesirable medication-induced harm due to residents receiving medications that were not ordered or incorrect doses of prescribed medications.

Inspectors wroteBased on personnel file review, staff interviews, and the job description, the facility failed to ensure the activities program was directed by a qualified professional.

Inspectors wroteBased on review of clinical records and policy, observations, and staff interviews the facility failed to ensure the environment for Resident # 58 remained free of accident hazards existing from medications at bedside and a potential risk of medication self-administration. The deficient practice of medication at bedside may result in undesirable medication-induced harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rate was below 5% after 3 medication errors were observed during a combined 27 randomly selected medication administration opportunities by four licensed nurses for residents # 448, # 38, # 99. The facility's medication error rate was 11.11% as a result of three of four licensed nurses having at least one medication administration error upon individual observation. The deficient practice of medication errors at or exceeding 5% may result in undesirable medication-induced harm.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure that expired medications and devices were not readily accessible for use in the medication supply room and medication cart according to professional standards. The deficient practice may result in the use of expired supplies against manufacturer recommendation resulting in undesirable harm or alterations in effectiveness of medications and devices.

Inspectors wroteBased on resident and staff interviews, a food test tray, and policy review, the facility failed to ensure food was provided that was palatable and at an appetizing temperature. The deficient practice has the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals.

Inspectors wroteBased on observations, staff interviews and facility policy, the facility failed to ensure that a unit refrigerator was maintained to ensure food items were dated, expired foods were not available for consumption, and that foods were distributed in a manner to prevent illness.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure three residents (#s 10, 42, and 44) with a diagnosis of a serious mental illness were referred to the appropriate state-designated mental health or intellectual disability authority for review. The sample size was 8. The deficient practice could result in necessary specialized services not being provided for residents who need it.

Inspectors wroteBased on clinical record reviews, staff and family interviews, and policy review, the facility failed to initiate a baseline care plan within the required timeframe and provide a summary of that baseline care plan to residents (#s 405, 506, and 510) and their representatives. The sample size was 31. The deficient practice could result in residents not having a plan of care and not being aware of their plan of care.

Inspectors wroteBased on the clinical record review, facility documents, staff interviews and facility policy, the facility failed to ensure that bathing assistance was provided for three residents (#s 38, 510, and 132). The sample size was 9. The deficient practice could result in residents' hygiene needs not being met.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that an allegation of staff to resident abuse was reported to the State agency within the required 2-hour timeframe for one resident (#19). The deficient practice could result in allegations of abuse not being reported.

Inspectors wroteBased on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to ensure one resident (#81) had a level I PASRR (Pre-admission Screening and Resident Review), upon admission. The sample size was 8. The deficient practice could result in necessary specialized services not being provided for residents who need it.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident's (#19) comprehensive care plan included diabetes management and related insulin use. The sample size was 31. The deficient practice may result in an incomplete plan of care for residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policies, the facility failed to ensure services provided to one resident (#16) met professional standards of quality care. The deficient practice could result in residents receiving services that do not meet standards of quality.

Inspectors wroteBased on the clinical record review and staff interviews, the facility failed to ensure that one sampled resident (#38) was provided care in accordance with professional standards of care regarding an ultrasound. The deficient practice could result in delayed treatment for residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#16) received care and treatments consistent with professional standards of practice to promote healing and prevention of pressure ulcers. The sample size was 4. The deficient practice could result in delayed healing of pressure ulcers.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#205) with extensive behavioral health needs was transferred or discharged due to her welfare, and/or her needs could not be met in the facility, and/or the safety of individuals in the facility were being endangered due to the clinical/behavioral needs of the resident.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to act upon the pharmacy Medication Regimen Review for one resident (#81). The sample size was 5. The deficient practice could result in MRRs not being followed through.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure one resident (#125) was consistently served food that accommodated the resident's food allergies. The sample size was 9. The deficient practice increases the risk for food-related allergic reactions.

Inspectors wroteBased on staff interview, facility policy, and review of the Center for Disease Control (CDC) recommendations, the facility failed to designate a qualified individual as the Infection Preventionist (IP) on an ongoing basis. The deficient practice could result in improper infection prevention practices within the facility.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that residents, their representatives and families were notified of positive COVID-19 cases occurring in the facility, within the required timeframe. The deficient practice could result in residents and their representatives/families not being aware of new COVID-19 cases in the facility and the actions implemented to reduce the risk of transmission.

Inspectors wroteBased on staff interview and facility policy, the facility failed to develop and implement their policy to ensure that contracted staff were vaccinated for COVID-19. The deficient practice may result in other staff not being vaccinated for COVID-19.

Inspectors wroteBased on personnel file review, staff interviews, and policy reviews, the facility failed to provide evidence that 1 out of 10 sampled staff (#143) received training regarding abuse, neglect, exploitation, misappropriation of resident property, and dementia management. The deficient practice could result in staff not being educated regarding abuse, neglect, exploitation, misappropriation of resident property, and dementia management.