Sandstone of Tucson Rehab Centre

In the surveyor’s words

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

• Actual harm, isolatedF600Apr 3, 2026

  Based 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. […]

• Actual harm, isolatedF600Apr 22, 2025

  Based 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. Findings include: -Regarding Resident #1 and #2 -Resident #1 was admitted to the facility on [DATE] with diagnosis that included spinal stenosis, Dementia, and major depressive disorder. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #1 completed a Brief Interview for Mental Status (BIMS) score of 09 indicating moderate cognitive mpairment. -Resident #2 was admitted to the facility on [DATE] with diagnosis that included rib fractures, anxiety disorder, low vision in the Right eye, psychosis and Dementia. […]

• Actual harm, isolatedF689Mar 23, 2023

  Based on clinical record review, facility documentation, staff interviews, and review of policy, the facility failed to ensure one resident (#5) received adequate supervision to avoid a preventable elopement. Three residents were sampled. The deficient practice may increase the risk for elopement, accidents and/or injuries. Findings include: Resident #5 admitted to the facility on [DATE] with diagnoses including epilepsy, not intractable, without status epilepticus, intracranial injury with loss of consciousness status unknown and amnesia. The emergency room Report dated 02/21/23 at 10:23 p.m. included that the resident's history was obtained over the phone from the resident's family who was his legal guardian. […]

• No harm, potential for more than minimal, patternF600Nov 20, 2025

  Based 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… […]

• No harm, potential for more than minimal, patternF757Dec 17, 2024

  Based 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. Findings include: -Resident #1 was admitted on [DATE] with diagnosis including unspecified atrial fibrillation, chronic kidney disease, cerebral infarction without residual effects, major depressive disorder-recurrent, unspecified psychosis, hallucinations, cognitive communication deficit. A review of the MDS (minimum data set) dated August 8, 2024 revealed a BIMS (brief interview of mental status) score of 06 indicating severe cognitive impairment. […]