54 Reports
Inspection Report — Mar 24, 2026
Date: Mar 24, 2026
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On-site other inspection of a Nursing Care Institution at Sandstone of Tucson Rehab Centre conducted 24 March 2026.
Findings
The inspection found five deficiencies related to emergency preparedness, sprinkler system maintenance, corridor doors, smoke barrier penetrations, and protective guards on light bulbs. Plans of correction were provided for all deficiencies.
Deficiencies (5)
§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a) — The facility failed to maintain, review, and update the Emergency Preparedness Plan annually, posing a potential risk that required revisions would not be recognized and implemented.
Sprinkler System - Maintenance and Testing — The facility failed to maintain sprinkler heads and ensure all parts of the sprinkler system met UL Listing requirements, including missing escutcheon plates, which could allow heat and smoke to affect other areas of the building.
Corridor - Doors — The facility failed to provide corridor doors in accordance with NFPA 101 - 2012 edition requirements, potentially affecting approximately 38 residents and staff in the event of a fire.
Subdivision of Building Spaces - Smoke Barrier Construction — The facility failed to properly fill penetrations of fire/smoke barriers, allowing smoke and heat to penetrate other areas, which could harm patients and staff during a fire.
Utilities - Gas and Electric Equipment — The facility failed to provide protective guards on light bulbs throughout the facility, risking accidental damage or fire that could harm patients.
Report Facts
Deficiencies cited: 5
Inspection Report — Feb 11, 2026
Complaint Investigation
Date: Feb 11, 2026
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On-site complaint investigation of complaints 00158101, 00158089, and 00158653 at a Nursing Care Institution, conducted 10-11 February 2026.
Complaint Details
An onsite complaint survey was conducted on February 10, 2026 through February 11, 2026 for the following intakes: 00158101, 00158089, and 00158653. Federal comments noted noncompliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, for intakes 2739700, 2739883, 2733485, 2724877, and 2734867.
Findings
The inspection found six deficiencies related to failure to report abuse allegations timely, failure to protect residents from abuse, and failure to obtain signed consent for psychotropic medication. Plans of correction were provided for all deficiencies.
Deficiencies (6)
R9-10-403 — The facility failed to ensure an allegation of abuse for one resident (#4) was reported to the State Agency within the required timeframe, risking continued abuse.
§483.12 — The facility failed to protect the rights of one resident (#6) to be free from abuse by another resident (#9), risking sustaining injuries.
The facility failed to ensure a signed consent was obtained before starting a new psychotropic medication for one resident (#4), risking uninformed responsible parties about medication risks and benefits.
§483.12(c) — The facility failed to ensure an allegation of abuse for one resident (#4) was reported to the State Agency within the timeframe established by regulations, risking continued abuse.
R9-10-410 — The facility failed to protect the rights of one resident (#6) to be free from abuse by another resident (#9), risking sustaining injuries.
R9-10-410 — The facility failed to ensure a signed consent was obtained before starting a new psychotropic medication for one resident (#4), risking uninformed responsible parties about medication risks and benefits.
Report Facts
Deficiencies cited: 6
Complaints investigated: 3
Complaints investigated: 5
Inspection Report — Jan 28, 2026
Complaint Investigation
Date: Jan 28, 2026
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On-site complaint investigation of multiple complaints including 2236460, 2235748, 2236442, 2236362, and 2236325 at a Nursing Care Institution, conducted 26-28 January 2026.
Complaint Details
The onsite complaint survey was conducted January 26-28, 2026 and investigated complaints 2236460, 2235748, 2236442, 2236362, 2236325, and multiple others including complaint numbers 2581018, 2567112, 2697205, 2236465, 2720350, 2716747, 2671363, 2661908, 2653312, 2235853, 2236467, 2236459, 2235746, 2236441, 2236361, and 2236333.
Findings
The inspection found 14 deficiencies related to failure to investigate alleged abuse and exploitation, protect resident rights, develop and revise care plans timely, and ensure resident safety and supervision.
Deficiencies (14)
R9-10-403 — The facility failed to maintain documentation that an alleged financial misappropriation of property involving residents #333 and #91 was thoroughly investigated.
The facility failed to protect resident #511's rights by not allowing her to have her own cell phone to access persons and services outside the facility, potentially violating residents’ rights.
The facility failed to protect resident #911 from physical abuse by another resident, risking further abuse and lack of appropriate action.
The facility failed to protect resident #333 from financial misappropriation/exploitation of property by another resident, risking further financial abuse.
§483.12(c) — The facility failed to maintain documentation that an alleged financial misappropriation involving residents #333 and #111 was thoroughly investigated, risking further financial abuse.
The facility failed to develop a baseline care plan within 48 hours of admission for resident #191, risking that immediate needs were not appropriately addressed.
The facility failed to review and revise the care plan for resident #191 after each fall incident, placing the resident at risk for more falls.
The facility failed to identify elopement risks and plan effective supervision for resident #888 and failed to ensure resident #511 was supervised during activities, risking avoidable accidents.
R9-10-407 — The facility failed to develop a baseline care plan within 48 hours of admission for resident #191 to meet immediate nursing care needs.
R9-10-410 — The facility failed to ensure resident #911 was not subjected to physical abuse by another resident.
R9-10-410 — The facility failed to protect resident #333 from financial misappropriation/exploitation of property by another resident.
R9-10-410 — The facility failed to protect resident #511's rights in a manner that promotes enhancement of quality of life by allowing her to have her own cell phone.
R9-10-414 — The facility failed to review and revise the care plan for resident #191 after each fall incident.
R9-10-425 — The facility failed to identify elopement risks and plan effective supervision for resident #888 and ensure safe conduct of activities for resident #511.
Report Facts
Deficiencies cited: 14
Inspection Report — Jan 5, 2026
Complaint Investigation
Date: Jan 5, 2026
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On-site complaint investigation of intakes #2694511, #2694786, and #2693631 at a Nursing Care Institution, conducted 5 January 2026.
Complaint Details
An onsite complaint survey was conducted on January 5, 2026 for the investigation of intakes #2694511, #2694786, and #2693631.
Findings
The inspection found two deficiencies related to the facility's failure to protect a resident from abuse by another resident. Both deficiencies were substantiated with clinical record reviews, interviews, and policy review.
Deficiencies (2)
§483.12 — The facility failed to protect resident #10’s rights to be free from abuse by another resident (#5), risking further incidents of resident-to-resident abuse.
R9-10-410 — The administrator failed to ensure that resident #10 was not subjected to abuse by another resident (#5).
Report Facts
Deficiencies cited: 2
Inspection Report — Dec 11, 2025
Complaint Investigation
Date: Dec 11, 2025
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On-site complaint investigation of intakes 00152654 and 00151196 at a Nursing Care Institution, conducted 10 through 11 December 2025.
Complaint Details
An onsite complaint survey was conducted on December 10 through 11, 2025 for the investigation of intake #00152654 and 00151196. Federal comments also referenced intakes #2687167 and 2673932.
Findings
The inspection found two deficiencies related to the facility's failure to protect a resident from verbal and physical abuse by another resident. The facility census was 122 at the time of the investigation.
Deficiencies (2)
§483.12 — The facility failed to protect the rights of one resident (#07) to be free from verbal and physical abuse by another resident (#33), risking the resident’s safety and potential harm.
R9-10-410 — The administrator failed to ensure that one resident (#07) was not subjected to verbal and physical abuse by another resident (#33), violating the resident’s right to safety.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 20, 2025
Complaint Investigation
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to multiple allegations and reports of abuse involving residents and staff at Sandstone of Tucson Rehab Centre, including staff to resident abuse, resident to resident abuse, and failure to timely report suspected abuse.
Complaint Details
The complaint investigation involved multiple allegations of abuse including a CNA hitting Resident #9, inappropriate touching of Resident #10 by CNAs, resident to resident altercations involving Residents #41, #42, #16, and #40, and failure to timely report an abuse allegation involving Resident #26. The investigation included interviews with staff, review of clinical records, care plans, incident reports, and facility policies. The allegations were substantiated with findings of abuse and inadequate facility response.
Findings
The facility failed to protect residents from abuse by staff and other residents, failed to update care plans or review effectiveness after abuse incidents, and failed to timely report allegations of abuse to the state agency. Several residents experienced physical and verbal abuse, and investigations revealed inadequate interventions and documentation.
Deficiencies (4)
Failed to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect by staff and other residents.
Failed to timely report suspected abuse to the state agency within required 2-hour timeframe.
Failed to update care plans or review effectiveness of interventions after incidents of resident to resident abuse.
Failed to protect resident from staff to resident abuse and failed to remove or discipline abusive staff appropriately.
Report Facts
Residents affected: 9
BIMS score: 0
BIMS score: 15
BIMS score: 1
BIMS score: 11
BIMS score: 15
Timeframe for abuse report: 2
Date of survey completion: Nov 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #198 | Certified Nursing Assistant (CNA) | Involved in hitting Resident #9 and suspended; agency CNA banned from agency |
| Staff #200 | Certified Nursing Assistant (CNA) | Reported abuse incident involving Resident #9 and staff #198 |
| Staff #196 | Certified Nursing Assistant (CNA) | Provided definition of abuse and reporting procedures |
| Staff #115 | Human Resource Director | Confirmed staff #198 was agency CNA and 'do not return' |
| Staff #38 | Administrator | Discussed abuse reporting and video footage retention |
| Staff #93 | Director of Nursing (DON) | Reviewed abuse investigations and expectations for reporting and removal of perpetrators |
| Staff #154 | Certified Nursing Assistant (CNA) | Involved in care of Resident #10 with allegations of rough treatment |
| Staff #155 | Licensed Practical Nurse (LPN) | Provided statements on abuse definitions and care refusal procedures |
| Staff #99 | Certified Nursing Assistant (CNA) | Provided statements on abuse and care refusal |
| Staff #118 | Certified Nursing Assistant (CNA) | Provided statements on abuse and care refusal |
| Staff #50 | Licensed Practical Nurse (LPN) | Provided statements on abuse examples and reporting requirements |
Inspection Report — Nov 19, 2025
Complaint Investigation
Date: Nov 19, 2025
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On-site complaint investigation of multiple intakes at a Nursing Care Institution, conducted 20 October 2025 through 22 October 2025.
Complaint Details
An onsite complaint licensure survey was conducted on October 20, 2025 through October 22, 2025 for the investigation of intakes #00148179, #00148177, #00148028, #00147608, #00147386, #00146774, #00146655, #00146654, #00146706, #00146590, #00146620, #00146618, #00146592, #00146431, #00146465, #00146218, #00146280, and #00147922. Federal complaint investigation included intakes #2646833, #2646815, #2645726, #2642295, #2639518, #2634116, #2633148, #2633133, #2633621, #2632239, #2632646, #2632642, #2632252, #2630940, #2631028, #2629705, #2629765, and #2644665.
Findings
The inspection found six deficiencies related to failure to prevent and address abuse and neglect, including failure to implement appropriate interventions and ensure residents were free from abuse by staff and other residents.
Deficiencies (6)
R9-10-403.F.1 — The facility failed to ensure appropriate interventions were implemented in accordance with professional standards to address suspected abuse, neglect, or exploitation.
R9-10-403.F.4 — The facility failed to ensure that one resident was free from physical abuse by other residents and that another resident was free from abuse by staff, risking further incidents of resident-to-resident abuse.
§483.12(a)(1) — The facility failed to ensure one resident was free from physical abuse by other residents and another resident was free from abuse by staff, risking further incidents of resident-to-resident abuse.
Policies and procedures — The facility failed to ensure policies and procedures prevented abuse and included required elements such as investigation and reporting, risking further incidents of resident-to-resident abuse.
§483.12(c) — The facility failed to ensure appropriate interventions were implemented to prevent further potential abuse, neglect, exploitation, or mistreatment during investigations, risking further injury.
R9-10-410.B.3.a — The facility failed to ensure one resident was free from physical abuse by other residents and another resident was free from abuse by staff.
Report Facts
Deficiencies cited: 6
Inspection Report — Nov 13, 2025
Complaint Investigation
Date: Nov 13, 2025
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On-site complaint investigation of complaints 2650863, 00148770, 00148771, 2653272, 00149035, 2654721, 00149200, 00149199, 2658547, 00149672, and 00149673 at a Nursing Care Institution, conducted 13 November 2025.
Complaint Details
The investigation of Complaints 2650863, 00148770, 00148771, 2653272, 00149035, 2654721, 00149200, 00149199, 2658547, 00149672, and 00149673 was conducted on November 13, 2025. The Federal investigation included complaints 2650863, 2651999, 2652007, 2653272, 2654315, 2654721, 2655312, 2655321, 2658547, 2660144, 2660171, and 2660739.
Findings
The inspection found two deficiencies related to the facility's failure to protect residents from abuse by other residents.
Deficiencies (2)
§483.12 — The facility failed to protect the rights of 2 of 8 sampled residents to be free from abuse by other residents, which could result in further abuse.
R9-10-410 — The administrator failed to ensure that 2 of 8 sampled residents were not subjected to abuse by other residents, risking additional harm.
Report Facts
Deficiencies cited: 2
Inspection Report — Oct 24, 2025
Complaint Investigation
Date: Oct 24, 2025
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On-site complaint investigation of complaints AZ00178048/2236254, AZ00178974/2236260, AZ00179020/2236261, AZ00182250/2236273, AZ00182313/2236271, and AZ00182583 at a Nursing Care Institution, conducted 23-24 October 2025 with an offsite follow-up on 13 November 2025.
Complaint Details
The Risk Based survey was conducted October 23, 2025 through October 24, 2025 with the following complaints: AZ00178048/2236254, AZ00178974/2236260, AZ00179020/2236261, AZ00182250/2236273, AZ00182313/2236271, AZ00182583. An offsite follow up survey was conducted on November 13, 2025. There were no deficiencies cited in the offsite follow-up.
Findings
The inspection found one deficiency related to failure to protect residents from abuse by other residents. The facility failed to ensure sufficient protection against resident-to-resident abuse for four residents.
Deficiencies (1)
R9-10-410 — The facility failed to protect the rights of four residents to be free from abuse by other residents, based on clinical record review, interviews, and policy review. This deficient practice could result in insufficient protection to prevent resident-to-resident abuse.
Report Facts
Deficiencies cited: 1
Complaints investigated: 6
Inspection Report — Sep 17, 2025
Complaint Investigation
Date: Sep 17, 2025
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On-site complaint investigation of complaints 00144638, 00143311, 2614553, and 2608347 at a Nursing Care Institution, conducted 17 September 2025.
Complaint Details
The onsite complaint survey was conducted on September 17, 2025 and investigated complaints #00144638, 00143311. Federal complaints #2614553 and 2608347 were also investigated. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Report Facts
Complaints investigated: 4
Inspection Report — Sep 3, 2025
Complaint Investigation
Date: Sep 3, 2025
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On-site complaint investigation of intake 00142736 and intake 2603790 at a Nursing Care Institution, conducted 3 September 2025.
Complaint Details
An onsite complaint survey was conducted on September 3, 2025 for intake 00142736. An onsite complaint survey was conducted on September 3, 2025 for intake 2603790.
Findings
This inspection found no deficiencies.
Inspection Report — Aug 25, 2025
Complaint Investigation
Date: Aug 25, 2025
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The inspection was conducted due to a complaint investigation regarding failure to protect residents from abuse, neglect, and failure to timely report incidents of resident-to-resident abuse.
Complaint Details
The complaint investigation focused on an incident on August 21, 2025, where Resident #4 threatened and attempted to hit Resident #2. The facility failed to update care plans, increase monitoring, or immediately separate the residents. Reporting to state agencies and family was delayed until August 22, 2025. Interviews with staff including the Director of Nursing and Certified Nursing Assistant revealed failures in timely reporting and appropriate follow-up actions. The allegation was substantiated.
Findings
The facility failed to protect residents from physical and verbal abuse by another resident, failed to implement policies consistently to prevent abuse and neglect, and failed to timely report allegations of abuse to appropriate state agencies and other mandated entities. The investigation verified the abuse allegation and identified deficiencies in monitoring, reporting, and care plan updates following the incident.
Deficiencies (3)
Failure to protect residents from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect.
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft.
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Date of incident: Aug 21, 2025
Date of report submission: Aug 22, 2025
Mental status score Resident #2: 2
Mental status score Resident #4: 3
Behavior shifts Resident #4: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant Staff 10 | Certified Nursing Assistant | Witnessed resident altercation and reported incident |
| Licensed Practical Nurse Staff 8 | Licensed Practical Nurse | Documented incident, conducted visual checks, and interviewed regarding abuse reporting procedures |
| Director of Nursing Staff 12 | Director of Nursing | Interviewed regarding incident awareness, reporting failures, and facility expectations |
| Assistant Director of Nursing Staff 14 | Assistant Director of Nursing | Became aware of incident from 24-hour report and involved in follow-up |
Inspection Report — Jul 16, 2025
Complaint Investigation
Date: Jul 16, 2025
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On-site complaint investigation of complaints 00136388, 00136334, 00136631, and 00136481 at a Nursing Care Institution, conducted 16 July 2025.
Complaint Details
A complaint investigation was performed on July 16, 2025 of the following complaints: 00136388, 00136334, 00136631, 00136481. Federal complaints investigated include 2561070, 2561491, 2563663, and 2563088.
Findings
The inspection found four deficiencies related to failure to report and protect residents from abuse. The facility failed to report an allegation of abuse and did not protect residents from abuse by other residents.
Deficiencies (4)
R9-10-403 — The facility failed to ensure that an allegation of abuse was reported to the State Agency for one resident (#69), risking unreported abuse allegations.
§483.12 — The facility failed to protect the rights of two residents (#69, #77) to be free from abuse by other residents (#81, #76), risking further abuse.
§483.12(c) — The facility failed to ensure that an allegation of abuse was reported to the State Agency for one resident (#69), risking unreported abuse allegations.
R9-10-410 — The facility failed to protect the rights of two residents (#69, #77) to be free from abuse by other residents (#81, #76), risking further abuse.
Report Facts
Deficiencies cited: 4
Complaints investigated: 8
Inspection Report — Jul 9, 2025
Complaint Investigation
Date: Jul 9, 2025
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On-site complaint investigation of intake #00135987 and intake #2236425 at a Nursing Care Institution, conducted 9 July 2025.
Complaint Details
An onsite complaint survey was conducted on July 9, 2025 for the investigation of intake #00135987 and intake #2236425. There are no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — May 20, 2025
Enforcement
Date: May 20, 2025
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Civil monetary penalty, action 00132457 (invoice INV-283034), assessed 20 May 2025.
Findings
A $500.00 penalty was assessed and paid in full on 26 July 2025.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — May 12, 2025
Complaint Investigation
Date: May 12, 2025
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On-site complaint investigation of complaints 00129614 and AZ00224437 at a Nursing Care Institution, conducted 12 May 2025.
Complaint Details
A complaint survey was conducted on May 12, 2025 for the investigation of intakes #'s: 00129614 and AZ00224437. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 2
Inspection Report — May 5, 2025
Complaint Investigation
Date: May 5, 2025
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On-site complaint investigation of complaints 00126246, 00125183, 00125493, 00124937, AZ00224036, AZ00224121, AZ00224059, and AZ00224003 at a Nursing Care Institution, conducted 5 May 2025.
Complaint Details
The investigation of complaint #'s: 00126246, 00125183, 00125493, and 00124937 was conducted on May 05, 2025. The investigation of complaint #'s: AZ00224036, AZ00224121, AZ00224059, AZ00224003 was conducted on May 05, 2025. There were no deficiencies found.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 8
Inspection Report — Apr 22, 2025
Complaint Investigation
Date: Apr 22, 2025
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On-site complaint investigation of intakes 00127043, 00126995, 00126977, 00126255, AZ00224199, AZ00224186, AZ00224185, and AZ00224138 at a Nursing Care Institution, conducted 18 through 22 April 2025.
Complaint Details
An onsite complaint investigation was conducted on April 18, 2025 through April 22, 2025 for the following intakes #00127043, 00126995, 00126977, 00126255. Federal comments also noted an onsite complaint investigation for intakes #AZ00224199, AZ00224186, AZ00224185, AZ00224138.
Findings
Two deficiencies were cited during this complaint investigation. No evidence was provided in the documentation for either deficiency.
Deficiencies (2)
§483.12 — No evidence text was provided regarding the facility's failure to ensure residents' freedom from abuse, neglect, misappropriation of property, and exploitation.
R9-10-414 — No evidence text was provided regarding the administrator's failure to ensure that the care plan assisted the resident in maintaining their highest practicable well-being.
Report Facts
Deficiencies cited: 2
Complaints investigated: 8
Inspection Report — Mar 31, 2025
Complaint Investigation
Date: Mar 31, 2025
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On-site complaint investigation of complaints 00123457, 00123716, 00123686, AZ00223887, AZ00223892, and AZ00223899 at a Nursing Care Institution, conducted 31 March 2025.
Complaint Details
An onsite complaint survey was conducted on March 31, 2025 for the following intakes: 00123457, 00123716, and 00123686. An onsite complaint survey was conducted on March 31, 2025 for the following intakes: AZ00223887, AZ00223892, AZ00223899.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 6
Inspection Report — Mar 21, 2025
Complaint Investigation
Date: Mar 21, 2025
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On-site complaint investigation of intake 00122949 and intake AZ00223826 at a Nursing Care Institution, conducted 20-21 March 2025.
Complaint Details
The onsite investigation of intake 00122949 was conducted on March 20, 2025 through March 21, 2025. The onsite investigation of intake AZ00223826 was conducted on March 20, 2025 through March 21, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Mar 13, 2025
Complaint Investigation
Date: Mar 13, 2025
Visit Reason
The inspection was conducted due to an allegation of verbal abuse and neglect involving resident #4, focusing on whether the facility reported the allegation to the State Survey Agency within the required timeframe.
Complaint Details
The complaint involved an allegation of verbal abuse and neglect by a CNA (staff #31) toward resident #4. The allegation was not reported to the State Survey Agency within the required timeframe despite being known by multiple staff. The allegation was substantiated by interviews and record review.
Findings
The facility failed to timely report an allegation of verbal abuse and neglect for resident #4 to the State Survey Agency. Interviews with multiple staff and review of records confirmed the allegation was known but not reported as required, posing a risk of continued abuse.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents Affected: 1
BIMS score: 14
Date of survey completion: Mar 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #31 | Certified Nursing Assistant (CNA) | Named in verbal abuse allegation |
| Staff #24 | Certified Nursing Assistant (CNA) | Interviewed regarding abuse reporting procedures |
| Staff #42 | Licensed Practical Nurse (LPN) | Interviewed regarding knowledge of abuse allegation and reporting |
| Staff #63 | Director of Nursing (DON) | Interviewed regarding reporting expectations and knowledge of allegation |
| Staff #57 | Certified Nursing Assistant (CNA) | Interviewed regarding abuse reporting and training |
| Staff #9 | Registered Nurse (RN) | Interviewed regarding abuse reporting procedures |
Inspection Report — Feb 19, 2025
Complaint Investigation
Date: Feb 19, 2025
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On-site complaint investigation of intakes 00115475, 00108734, AZ00223382, AZ00223420, and AZ00223497 at a Nursing Care Institution, conducted 18-19 February 2025.
Complaint Details
An onsite complaint survey was conducted on February 18, 2025 through February 19, 2025 for the following intakes: 00115475, 00108734, AZ00223382, AZ00223420, AZ00223497. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 5
Inspection Report — Jan 28, 2025
Complaint Investigation
Date: Jan 28, 2025
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On-site complaint investigation of intakes AZ00221948, AZ00221952, and AZ00221950 at a Nursing Care Institution, conducted 28 January 2025.
Complaint Details
An onsite complaint survey was conducted on January 28, 2025 for the following intakes: AZ00221948, AZ00221952, and AZ00221950. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Dec 17, 2024
Complaint Investigation
Date: Dec 17, 2024
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The inspection was conducted due to complaints regarding failure to provide appropriate treatment and care according to professional standards, specifically related to neurochecks after a fall and monitoring behaviors prior to medication administration for residents.
Complaint Details
The investigation was complaint-related, focusing on failure to provide appropriate neurochecks after a fall and failure to monitor behaviors before medication administration. The complaint was substantiated based on clinical record review, staff interviews, and policy review.
Findings
The facility failed to ensure that one resident received treatment and care according to professional standards, including inadequate neurochecks after an unwitnessed fall and failure to monitor and document behaviors prior to medication administration for two residents. Interviews with staff and review of policies confirmed these deficiencies, which could lead to harm such as missed brain injuries or over-medication.
Deficiencies (2)
Failure to conduct and document neurochecks as required after an unwitnessed fall for resident #2.
Failure to monitor and document behaviors prior to medication administration for residents #1 and #2.
Report Facts
Sample size: 3
Fall assessment score: 65
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/staff #181) | Interviewed regarding neurochecks and behavior tracking | |
| Registered Nurse (RN/staff #151) | Interviewed regarding neurochecks and medication behavior tracking | |
| Assistant Director of Nursing (ADON/staff #199) | Interviewed regarding neurochecks and medication behavior tracking | |
| Director of Nursing (DON/staff #16) | Interviewed regarding neurochecks and medication behavior tracking |
Inspection Report — Dec 17, 2024
Annual Inspection
Date: Dec 17, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication administration, and neurological evaluation following incidents including a resident fall and medication monitoring.
Findings
The facility failed to ensure appropriate treatment and care for a resident who experienced a fall, including incomplete neurological checks. Additionally, the facility did not monitor or document behaviors prior to medication administration for two residents, risking over-medication.
Deficiencies (2)
Failed to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically incomplete neurochecks after a resident fall.
Failed to ensure each resident’s drug regimen was free from unnecessary drugs by not monitoring and documenting behaviors prior to medication administration for 2 out of 3 residents sampled.
Report Facts
Sample size: 3
Fall assessment score: 65
BIMS score: 6
Neurocheck entries: 1
Expected neurocheck entries: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/staff #181) | Interviewed regarding neurocheck procedures and behavior tracking | |
| Registered Nurse (RN/#151) | Interviewed regarding neurocheck procedures and medication behavior tracking | |
| Assistant Director of Nursing (ADON/#199) | Interviewed regarding neurocheck expectations and medication behavior tracking | |
| Director of Nursing (DON/staff #16) | Interviewed regarding neurocheck and medication behavior monitoring expectations |
Inspection Report — Dec 2, 2024
Complaint Investigation
Date: Dec 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of abuse involving residents #114 and #129, specifically concerning failure to protect residents from abuse including sexual abuse and neglect.
Complaint Details
The complaint investigation substantiated incidents where resident #129 was found with his hand inside resident #114's brief without consent. Both residents were cognitively impaired and unable to consent. Staff interviews revealed inadequate supervision and staffing issues contributing to the incident.
Findings
The facility failed to ensure residents were free from abuse, including incidents where resident #129 was found touching resident #114 inappropriately. Both residents had severe cognitive impairments and were on frequent safety checks, but staff failed to adequately monitor and redirect them. Interviews with staff and nursing leadership confirmed inadequate supervision and inconsistent care plan updates.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect.
Report Facts
Level of Harm: 1
Residents Affected: 2
BIMS Score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant staff #27 | Certified Nursing Assistant | Reported the incident and described staffing and supervision issues |
| Certified Nursing Assistant staff #81 | Certified Nursing Assistant | Found residents during the incident and reported details |
| Licensed Practical Nurse staff #14 | Licensed Practical Nurse | Provided information about residents' conditions and care unit |
| Registered Nurse staff #30 | Registered Nurse | Described response actions and care plan update process |
| Director of Nursing staff #43 | Director of Nursing | Discussed care plan updates, residents' cognitive status, and consent capability |
Inspection Report — Nov 25, 2024
Complaint Investigation
Date: Nov 25, 2024
Visit Reason
On-site complaint investigation of intake AZ00218556 at a Nursing Care Institution, conducted 25 November 2024.
Complaint Details
The onsite investigation of intake AZ00218556 was conducted on Novemnber 25, 2024. No deficiencies were cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Oct 29, 2024
Complaint Investigation
Date: Oct 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident physical abuse involving two residents at the facility.
Complaint Details
The complaint investigation found that resident #2, who required one-to-one supervision, was not adequately watched by staff #46 CNA, allowing resident #2 to leave the bathroom and physically abuse resident #1. The incident was substantiated with multiple staff interviews and documentation including a disciplinary notice for staff #46.
Findings
The facility failed to ensure that two residents were free from physical abuse when resident #2 hit resident #1 multiple times in the head and face with a television remote control. The incident occurred due to inadequate supervision by staff assigned as one-on-one for resident #2, which allowed the altercation to happen.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident due to inadequate supervision.
Report Facts
Date of incident: Oct 19, 2024
Date of disciplinary notice: Oct 21, 2024
Date of resident #2 transfer: Oct 25, 2024
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #46 CNA (Certified Nursing Assistant) | Assigned one-on-one staff for resident #2 who failed to supervise, allowing the abuse incident | |
| Staff #10 CNA | Interviewed staff aware of the incident and supervision requirements | |
| Staff #30 RN (Registered Nurse) | Interviewed staff who explained supervision expectations and incident details | |
| Staff #118 DON (Director of Nursing) | Interviewed staff who stated expectations for resident safety and supervision |
Inspection Report — Sep 26, 2024
Complaint Investigation
Date: Sep 26, 2024
Visit Reason
On-site complaint investigation of complaint AZ00216407 at a Nursing Care Institution, conducted 24 through 26 September 2024.
Complaint Details
An onsite investigation of complaint #AZ00216407 was conducted from September 24, 2024 through September 26, 2024. The following deficiencies were cited: failure to prevent elopement and lack of security door policies.
Findings
The inspection found two deficiencies related to failure to prevent an avoidable elopement of a resident from the secured Behavioral Health Unit. The facility lacked a policy for security doors and staff allowed the resident to exit unsupervised, placing the resident at risk in the community.
Deficiencies (2)
§483.25(d) — The facility failed to ensure an avoidable elopement was prevented, resulting in a resident leaving the secured unit unsupervised and exposed to unsafe situations in the community.
R9-10-425 — The facility failed to maintain premises free from conditions that could cause physical injury by allowing a resident to exit the secured unit without proper supervision or security measures in place.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Certified Nursing Assistant | Observed kitchen staff let resident out of secured unit and attempted to redirect resident back. |
| Staff #9 | Licensed Practical Nurse | Described security door procedures and alerted staff to resident elopement. |
| Staff #5 | Cook | Let resident out of secured unit believing resident was a visitor. |
| Staff #8 | Director of Nursing | Provided expectations for staff regarding secured unit entry and exit and described risks of elopement. |
Inspection Report — Aug 7, 2024
Complaint Investigation
Date: Aug 7, 2024
Visit Reason
On-site complaint investigation of intake numbers AZ00214218 and AZ00214217 at a Nursing Care Institution, conducted 7 August 2024.
Complaint Details
An onsite complaint survey was conducted on August 7, 2024 for the investigation of intake # AZ00214218 and intake # AZ00214217. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 22, 2024
Complaint Investigation
Date: Jul 22, 2024
Visit Reason
On-site complaint investigation of intake AZ00213389 at a Nursing Care Institution, conducted 22 July 2024.
Complaint Details
An onsite complaint survey was conducted on July 22, 2024 for the investigation of intake # AZ00213389. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Jun 18, 2024
Complaint Investigation
Date: Jun 18, 2024
Visit Reason
On-site complaint investigation of intakes AZ00211856, AZ00211813, AZ00211854, and AZ00211812 at a Nursing Care Institution, conducted 18 June 2024.
Complaint Details
An onsite complaint survey was conducted on June 18, 2024 for the investigation of intake #s AZ00211856 and AZ00211813. Federal comments note investigation of intake #s AZ00211854 and AZ00211812. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Inspection Report — May 29, 2024
Complaint Investigation
Date: May 29, 2024
Visit Reason
On-site complaint investigation of intake #AZ00210957 and #AZ00210956 at a Nursing Care Institution, conducted 29 May 2024.
Complaint Details
The complaint survey was conducted on May 29, 2024 for the investigation of intake #AZ00210957 and intake #AZ00210956. There were no deficiencies cited.
Findings
This inspection found no deficiencies or citations.
Inspection Report — May 16, 2024
Complaint Investigation
Date: May 16, 2024
Visit Reason
On-site complaint investigation of intake numbers AZ00210415, AZ00210028, AZ00208002 and AZ00206348 at a Nursing Care Institution, conducted 16 May 2024.
Complaint Details
The complaint survey was conducted on May 16, 2024 for the investigation of intake numbers AZ00210415, AZ00210028, AZ00208002 and AZ00206348. Federal comments referenced intake numbers AZ00210413, AZ00210027, AZ00208001 and AZ00206347 with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Mar 18, 2024
Complaint Investigation
Date: Mar 18, 2024
Visit Reason
On-site complaint investigation of intake AZ00207436 at a Nursing Care Institution, conducted 18 March 2024.
Complaint Details
An onsite complaint survey was conducted on March 18, 2024 for the investigation of intake # AZ00207436. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Feb 2, 2024
Complaint Investigation
Date: Feb 2, 2024
Visit Reason
On-site complaint investigation of intakes AZ00205916, AZ00205913 and AZ00205944 at a Nursing Care Institution, conducted 2 February 2024.
Complaint Details
A complaint survey was conducted on February 2, 2024 for the investigation of intake #AZ00205916. Federal comments note investigations of intake #AZ00205913 and AZ00205944. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Report Facts
Complaints investigated: 3
Inspection Report — Nov 3, 2023
Annual Inspection
Date: Nov 3, 2023
Visit Reason
On-site complaint investigation and annual recertification survey conducted from October 30, 2023 through November 3, 2023, including investigation of complaints AZ00191597 and AZ00189559 at a Nursing Care Institution.
Complaint Details
The recertification survey was conducted in conjunction with investigation of complaints AZ00191597 and AZ00189559. Federal comments also referenced complaints AZ00199359, AZ00191672, AZ00191598, AZ00191597, AZ00191433, AZ00191283, AZ00191129, AZ00190946, AZ00190294, AZ00190035, AZ00189558, AZ00189559, and AZ00189537.
Findings
The inspection identified 25 deficiencies including failures in timely PASARR level II referral, meal service dignity, resident council meeting regularity and responsiveness, medication administration errors, expired medication storage, and resident rights notification. Plans of correction were provided for all deficiencies.
Deficiencies (24)
R9-10-403.C.2.a — The facility failed to ensure a timely referral for a PASARR level II determination for resident #38, delaying appropriate service level assessment despite a history of suicide attempts.
§483.10(a) — The facility failed to ensure meals were served to residents seated together at the same time, compromising resident dignity and mental health.
§483.10(f)(5) — The facility was unable to demonstrate that resident council meetings were held regularly or that grievances and recommendations were addressed and communicated back to residents.
§483.10(g) — The facility failed to ensure resident #401 was informed of their rights during their stay, as no copy of resident rights was provided upon admission.
§483.12 — The facility failed to prevent physical abuse of resident #51 by resident #154 and did not adequately care plan for aggressive behaviors.
§483.20(k) — The facility failed to ensure timely PASARR level II referral for resident #38, missing inpatient psychiatric hospitalization information in the screening.
§483.21(b)(2) — The facility failed to ensure resident #114 or their representative participated in the care planning process, with no documentation of invitations or attendance.
§483.21(b)(3)(i) — The facility failed to administer medications as ordered for residents #448, #38, and #99, resulting in incorrect medication administration.
§483.24(c)(2) — The facility failed to maintain a safe environment for resident #58 by allowing medications to be at bedside without proper self-administration approval.
R9-10-406.I.2 — The facility failed to ensure the activities program was directed by a qualified professional, as the Activity Director lacked required training.
§483.45(f)(1) — The facility's medication error rate was 11.11%, exceeding the 5% threshold, due to three medication errors observed among four licensed nurses.
§483.45(g) and §483.45(h) — The facility failed to ensure expired medications and devices were not accessible in the medication supply room and medication cart.
§483.60(d) — The facility failed to provide food that was palatable and at an appetizing temperature, with multiple resident complaints and observations of cold food.
§483.60(i) — The facility failed to maintain a resident refrigerator free of expired and undated food items and failed to cover food and drinks during distribution.
R9-10-410.A.2 — The facility failed to provide resident #401 a written copy of resident rights at admission as required.
R9-10-410.B.2 — The facility failed to ensure meals were served to residents seated together at the same time, compromising dignity.
R9-10-410.B.3.a — The facility failed to prevent physical abuse of resident #51 by resident #154 and lacked appropriate care planning for aggressive behaviors.
R9-10-410.B.4.i — The facility failed to hold regular resident council meetings and did not provide documented responses to grievances and recommendations.
R9-10-414.A.1.d.xvii — The facility failed to ensure resident #114 or their representative participated in the comprehensive assessment and care planning process.
R9-10-414.B.3.b — The facility failed to provide nursing care that assists residents in maintaining their highest practicable well-being, including medication administration and environment safety.
R9-10-421.B.3.a — The facility failed to administer medications in compliance with orders, resulting in medication errors for residents #448, #38, and #99.
R9-10-421.D.3.a — The facility failed to establish policies and procedures to protect residents by allowing expired medications and supplies to remain accessible.
R9-10-423.A.3.b — The facility failed to properly store, refrigerate, and reheat food to meet dietary needs, including maintaining dated and non-expired food items.
R9-10-423.B.1.a — The facility failed to prepare food using methods that conserve nutritional value, flavor, and appearance, resulting in resident dissatisfaction.
Report Facts
Deficiencies cited: 25
Complaints investigated: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #8 | Director of Social Services | Interviewed regarding PASARR referral and resident council meetings. |
| Staff #81 | Food Service Director | Interviewed regarding meal service practices and food safety. |
| Staff #150 | Administrator | Interviewed regarding meal service and resident council expectations. |
| Staff #44 | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors. |
| Staff #17 | Registered Nurse | Observed and interviewed regarding medication administration errors. |
| Staff #56 | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors and medication at bedside. |
| Staff #24 | Director of Nursing | Interviewed regarding medication errors, care planning, and medication storage. |
| Staff #69 | Assistant Director of Nursing | Interviewed regarding admission packets and medication storage. |
| Staff #80 | Activities Director | Interviewed regarding qualifications and resident council meetings. |
| Staff #63 | Administrator | Interviewed regarding care planning and resident council expectations. |
| Staff #131 | Licensed Practical Nurse | Interviewed regarding resident self-administration of medications. |
| Staff #140 | Licensed Practical Nurse | Interviewed regarding care planning for aggressive residents. |
| Staff #147 | Licensed Practical Nurse | Observed medication storage and interviewed regarding expired medications. |
| Staff #58 | Director of Human Resources | Interviewed regarding Activities Director qualifications. |
Inspection Report — Nov 3, 2023
Date: Nov 3, 2023
Visit Reason
On-site other inspection of a Nursing Care Institution at Sandstone of Tucson Rehab Centre conducted 3 November 2023. The inspection included a recertification survey for Medicare under the Life Safety Code 2012.
Findings
The inspection found five deficiencies related to emergency preparedness, delayed egress door signage and force requirements, door maintenance, smoke barrier penetrations, and lack of an alarm annunciator for the diesel generator. The facility acknowledged all findings during the exit conference.
Deficiencies (5)
Based on document review and interview, the facility failed to maintain, review and update the Emergency Preparedness Plan annually, posing a potential risk that required revisions will not be recognized and revised as needed.
NFPA 101 Life Safety Code 2012, Chapter 19, Section 19.2.2.2.4 — The facility failed to have required signage on three delay egress exit doors and one door required 29 lbf to set the alarm in motion, exceeding the 15 lbf limit, which could cause confusion and harm in an emergency.
NFPA 101 Life Safety Code 2012, Chapter 19, Section 19.3.6.3.5 — The facility failed to maintain several doors, including missing latching hardware, gaps, propped open doors, and missing closing arms, which could allow heat and smoke to transfer and cause harm.
NFPA 101 Life Safety Code 2012, Chapter 19, Section 19.3.7.3 — The facility failed to fill penetrations in smoke barriers and fire walls, allowing smoke and heat to penetrate other wings or the whole facility, which could cause harm during a fire.
NFPA 101 2012 Life Safety Code and NFPA 99 Chapter 6 Section 6.4.1.1.17 — The facility failed to provide a storage battery powered alarm annunciator for the diesel generator, risking harm to patients and staff during a power outage.
Report Facts
Deficiencies cited: 5
Inspection Report — Nov 3, 2023
Routine
Date: Nov 3, 2023
Visit Reason
Routine inspection conducted to assess compliance with regulatory standards including resident rights, care planning, medication administration, food safety, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to serve meals simultaneously to residents at tables, irregular resident council meetings with lack of grievance follow-up, failure to provide resident rights information, inadequate abuse prevention care planning, untimely PASARR referrals, lack of resident participation in care planning, medication administration errors, expired medications and supplies, inadequate activities program staffing qualifications, unsafe medication storage practices, and food safety concerns including improper food temperatures and unsanitary resident refrigerators.
Deficiencies (12)
Meals were not provided to residents seated together at the same time, compromising dignity and mental health.
Resident council meetings were irregular and grievances were not addressed or documented.
One resident was not informed of their rights during their stay.
Failure to ensure one resident was not physically abused by another resident; inadequate care planning for aggressive behaviors.
Failure to obtain timely PASARR level II referrals for two residents.
Failure to ensure one resident or representative participated in care planning process.
Medication administration errors observed for three residents involving wrong medication or dose.
Activities program directed by staff lacking required qualifications.
Medications found at bedside without proper authorization and risk of self-administration.
Expired medications and supplies found in medication storage and carts.
Food served was not consistently palatable or at safe, appetizing temperatures.
Resident refrigerator was unsanitary, contained expired and undated food items, and food was not properly covered during distribution.
Report Facts
Medication administration opportunities observed: 27
Medication errors observed: 3
Medication error rate: 11.11
Tube feed tubing expired devices: 13
Food test tray temperatures: 123
Food test tray temperatures: 106
Food test tray temperatures: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding meal service and food safety concerns | |
| Administrator | Interviewed regarding meal service, resident council, care planning, and food safety | |
| Director of Nursing | Interviewed regarding medication errors, abuse prevention, and medication storage | |
| Licensed Practical Nurse (Staff #44) | Observed and interviewed regarding medication administration error | |
| Registered Nurse (Staff #17) | Observed and interviewed regarding medication administration error | |
| Licensed Practical Nurse (Staff #56) | Observed and interviewed regarding medication administration error and medication at bedside | |
| Director of Social Services (Staff #8) | Interviewed regarding resident council, grievance process, PASARR referrals, and care planning | |
| Activities Director (Staff #80) | Personnel file reviewed and interviewed regarding qualifications | |
| Assistant Director of Nursing (Staff #69) | Interviewed regarding resident council, medication at bedside, and resident refrigerator | |
| Licensed Practical Nurse (Staff #131) | Interviewed regarding medication self-administration and risks | |
| Director of Human Resources (Staff #58) | Interviewed regarding activities director qualifications | |
| Ombudsman (Individual #148) | Interviewed regarding resident council meetings and grievances |
Inspection Report — Sep 1, 2023
Annual Inspection
Date: Sep 1, 2023
Visit Reason
Annual survey inspection of Sandstone of Tucson Rehab Centre to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Sep 1, 2023
Date: Sep 1, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Sandstone of Tucson Rehab Centre, summarizing the findings of a regulatory survey completed on 2023-09-01.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Aug 23, 2023
Complaint Investigation
Date: Aug 23, 2023
Visit Reason
On-site complaint investigation of intake #AZ00199019 and #AZ00199017 at a Nursing Care Institution, conducted 22-23 August 2023.
Complaint Details
The complaint survey was conducted on August 22 through 23, 2023 for the investigation of intake #AZ00199019 and intake #AZ00199017. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Aug 14, 2023
Complaint Investigation
Date: Aug 14, 2023
Visit Reason
On-site complaint investigation of complaints AZ00197765 and AZ00197763 at a Nursing Care Institution, conducted 24 July through 14 August 2023.
Complaint Details
The investigation of complaint AZ00197765 was conducted on July 24, 2023 through August 14, 2023. The investigation of complaint AZ00197763 was conducted on July 24, 2023 through August 14, 2023. No deficiency was cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 3, 2023
Complaint Investigation
Date: Aug 3, 2023
Visit Reason
On-site complaint investigation of multiple complaints including AZ00183495, AZ00184465, and AZ00184032 at a Nursing Care Institution, conducted 31 July 2023 through 3 August 2023.
Complaint Details
A complaint investigation was conducted from July 31, 2023 through August 3, 2023 for the investigation of intake numbers AZ00183495, AZ00184465, AZ00184032, AZ00184128, AZ00198601, AZ00184450, AZ00183653, AZ00186312, AZ00185334, AZ00184569, AZ00184140, AZ00194475, AZ00184562, AZ00197477, AZ00177617, AZ00195928, AZ00195622, AZ00185696, AZ00189872, AZ00195647, AZ00193218, AZ00191225, AZ00186835. Federal complaint survey also investigated intake numbers AZ00186310, AZ00185333, AZ00184568, AZ00184139, AZ00194474, AZ00184561, AZ00197476, AZ00177616, AZ00195927, AZ00195621, AZ00185694, AZ00148773, AZ00189871, AZ00195644, AZ00193216, AZ00191224, AZ00186833, AZ00149082, AZ00193774, AZ00183495, AZ00184465, AZ00184032, AZ00184128, AZ00198601, AZ00184450 and AZ00183653.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Jul 15, 2023
Complaint Investigation
Date: Jul 15, 2023
Visit Reason
On-site complaint investigation of complaints AZ00191159 and AZ00191158 at a Nursing Care Institution, conducted 15 July 2023.
Complaint Details
The investigation of complaint AZ00191159 was conducted on July 10, 2023 through July 15, 2023. The investigation of complaint AZ00191158 was conducted on July 10, 2023 through July 15, 2023. No deficiency was cited.
Findings
No deficiencies were found during this complaint investigation.
Inspection Report — Jun 30, 2023
Complaint Investigation
Date: Jun 30, 2023
Visit Reason
On-site complaint investigation of intake AZ00196882 at a Nursing Care Institution, conducted 27 through 30 June 2023.
Complaint Details
An onsite survey was conducted on June 27 through June 30, 2023 for the investigation of intake #AZ00196882. No deficiencies were cited. The complaint survey was conducted on June 27 through June 30, 2023 for the investigation of intake #AZ00196882. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jun 15, 2023
Complaint Investigation
Date: Jun 15, 2023
Visit Reason
On-site complaint investigation of complaint AZ00196552 at a Nursing Care Institution, conducted 14 and 15 June 2023.
Complaint Details
An investigation of complaint AZ00196552 was conducted June 14 and 15, 2023. The complaint involved concerns about a resident eloping from the facility and inadequate supervision.
Findings
The inspection found two deficiencies related to the facility's failure to prevent a resident from eloping and neglect in supervision. The facility did not ensure adequate monitoring and safety measures to prevent the resident from leaving unattended.
Deficiencies (2)
§483.25(d) — The facility failed to ensure one resident did not elope, despite known moderate elopement risk and lack of Leave of Absence authorization. Staff failed to adequately monitor the resident, who was found outside unsupervised and left the facility without proper authorization.
R9-10-410 — The facility failed to prevent neglect by not ensuring adequate supervision of a resident at moderate risk of elopement. Staff did not consistently monitor the resident, who left the facility unattended and was not located promptly.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #80 | Licensed Practical Nurse | Interviewed regarding resident elopement and monitoring failures. |
| Staff #120 | Licensed Practical Nurse / Unit Manager | Interviewed regarding resident elopement and monitoring failures. |
| Staff #60 | Certified Nursing Assistant | Interviewed regarding resident elopement and monitoring failures. |
| Staff #22 | Certified Nursing Assistant | Interviewed regarding resident supervision and smoking area monitoring. |
| Staff #128 | Receptionist | Interviewed regarding monitoring residents at the reception desk and smoking area. |
| Staff #26 | Receptionist | Interviewed regarding logging residents in and out and monitoring residents on camera. |
| Staff #19 | Director of Nursing | Interviewed regarding expectations for resident supervision and elopement risk. |
| Staff #1 | Administrator | Interviewed regarding resident elopement and facility policies. |
Inspection Report — May 9, 2023
Enforcement
Date: May 9, 2023
Visit Reason
Civil monetary penalty, action 00113380 (invoice INV-259714), assessed 9 May 2023.
Findings
A $500.00 penalty was assessed and paid in full on 10 August 2023.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Apr 18, 2023
Complaint Investigation
Date: Apr 18, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of abuse among residents at the facility, focusing on incidents involving multiple residents exhibiting aggressive and harmful behaviors toward each other.
Complaint Details
The complaint investigation was substantiated with findings of multiple incidents of resident-to-resident abuse, including hitting, striking with objects, and physical altercations. The facility documented incidents involving residents #3, #15, #24, #31, #18, and #9, with some residents requiring hospital evaluation. Staff interviews confirmed the abuse and described the facility's efforts to monitor and manage aggressive behaviors.
Findings
The facility failed to ensure that three residents (#3, #24, and #18) were free from abuse by other residents. Multiple incidents of physical aggression, hitting, and assault among residents were documented, with minimal harm or potential for actual harm noted. Staff interviews and clinical record reviews confirmed these events and the facility's response.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect.
Report Facts
BIMS score: 0
BIMS score: 6
BIMS score: 15
BIMS score: 12
Medication dosage: 0.5
Laceration size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN staff #125 | Registered Nurse | Provided interview details regarding abuse definitions and resident behaviors. |
| LPN staff #92 | Licensed Practical Nurse | Described resident #9's aggressive behaviors and conflict with roommate. |
| DON staff #70 | Director of Nursing | Discussed facility efforts to prevent abuse and described resident incidents. |
| ADON staff #8 | Assistant Director of Nursing | Reported on abuse incidents involving residents #24 and #31 and facility response. |
Inspection Report — Mar 23, 2023
Complaint Investigation
Date: Mar 23, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision to prevent a resident's elopement.
Complaint Details
The investigation was triggered by a complaint related to resident #5's elopement. The resident had a history of elopement and was placed on a secured behavioral unit. The facility did not substantiate the resident leaving as an elopement because he was alert and oriented, but the event was considered a failure in supervision. The resident was found off-site with family after leaving through a window from which the latch and alarm batteries had been removed.
Findings
The facility failed to provide adequate supervision to resident #5, who eloped by climbing out of a secured window and leaving the premises. Interviews and documentation revealed lapses in communication about the resident's elopement risk and inconsistent monitoring practices. The resident was found off-site with family after the elopement. The facility's policies on safety, supervision, and elopement risk were reviewed and found to require proper implementation.
Deficiencies (1)
Failure to ensure adequate supervision to prevent resident elopement.
Report Facts
Elopement Risk Assessment Score: 8
Date of elopement event: Feb 24, 2023
Monitoring interval: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | RNUM | Provided written statement about resident's elopement risk and communication prior to resident's arrival. |
| Licensed Practical Nurse | LPN | Interviewed regarding resident monitoring and knowledge of elopement risk. |
| Certified Nursing Assistant | CNA | Interviewed about frequency of resident checks and monitoring practices. |
| Facility Administrator | Administrator | Interviewed about resident placement, elopement definition, and notification procedures. |
| Licensed Practical Nurse | LPN | Night shift nurse who last saw resident and identified resident missing the following morning. |
| Director of Nursing | DON | Interviewed about care plan expectations and monitoring requirements for elopement risk. |
Inspection Report — Sep 15, 2022
Complaint Investigation
Date: Sep 15, 2022
Visit Reason
The inspection was conducted due to complaint investigations regarding allegations of staff to resident abuse, failure to refer residents with serious mental illness to appropriate authorities, failure to initiate baseline care plans timely, incomplete care plans, failure to meet professional standards of care, inadequate bathing assistance, delayed diagnostic testing, pressure ulcer care deficiencies, behavioral health safety concerns, medication regimen review follow-up failures, food allergy accommodations, infection preventionist designation, COVID-19 notification failures, contract staff vaccination tracking, and staff training deficiencies.
Complaint Details
The visit was complaint-related involving allegations of abuse, neglect, failure to provide appropriate care and services, and regulatory noncompliance in multiple areas as detailed in the findings.
Findings
The facility was found deficient in multiple areas including failure to timely report suspected abuse, failure to refer residents with serious mental illness for PASRR Level II evaluations, failure to initiate baseline care plans within required timeframes, incomplete care plans missing diabetes management, failure to meet professional standards in enteral feeding and medication administration, inadequate bathing assistance, delayed ultrasound testing, inadequate pressure ulcer care and repositioning, failure to transfer or discharge a resident with unsafe behavioral health needs, failure to act on pharmacy medication regimen review recommendations, failure to accommodate resident food allergies, failure to designate a qualified infection preventionist, failure to timely notify residents and families of COVID-19 cases, failure to track vaccination status of contract staff, and failure to provide required staff training on abuse and dementia care.
Deficiencies (15)
Failure to timely report suspected staff to resident abuse within required 2-hour timeframe.
Failure to refer residents with serious mental illness to appropriate state-designated mental health authorities for PASRR Level II evaluation.
Failure to initiate baseline care plans within required 48 hours and failure to provide summary to residents and representatives.
Incomplete comprehensive care plan for resident #19 missing diabetes management and insulin use.
Failure to meet professional standards of care in enteral feeding administration and PICC line medication administration by untrained staff.
Failure to provide bathing assistance twice weekly for residents #38, #510, and #132.
Failure to provide timely ultrasound testing for resident #38 with STAT order.
Failure to provide appropriate pressure ulcer care including turning/repositioning every 2 hours and lack of physician orders for pressure relief surfaces.
Failure to transfer or discharge resident #205 with extensive behavioral health needs endangering self and others.
Failure to act upon pharmacy medication regimen review recommendations for resident #81 regarding heparin discontinuation and Furosemide hold parameters.
Failure to ensure resident #125 was consistently served food that accommodated food allergies.
Failure to designate a qualified infection preventionist on an ongoing basis.
Failure to timely notify residents, representatives, and families of positive COVID-19 cases in the facility.
Failure to track and ensure COVID-19 vaccination status of contracted staff.
Failure to provide evidence of required training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management for contracted staff member.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Staff affected: 2
Staff affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #141 | Interim Director of Nursing | Interviewed regarding multiple deficiencies including abuse reporting, care plans, professional standards, COVID-19 notification, and staff training. |
| Staff #120 | Administrator | Interviewed regarding abuse reporting, PASRR process, and staff training. |
| Staff #61 | Director of Social Services | Interviewed regarding PASRR referrals and mental health services. |
| Staff #128 | Licensed Practical Nurse Manager | Interviewed regarding care plans, bathing assistance, and pressure ulcer care. |
| Staff #3 | Dietary Manager | Interviewed regarding food allergy incident. |
| Staff #70 | Registered Nurse Wound Care Nurse | Observed and interviewed regarding pressure ulcer care and turning/repositioning. |
| Staff #102 | Certified Nursing Assistant | Interviewed regarding bathing assistance and shower documentation. |
| Staff #143 | Registered Nurse (Contracted) | Interviewed regarding lack of abuse and dementia training. |
| Staff #80 | Licensed Practical Nurse | Interviewed regarding behavioral health safety concerns. |
| Staff #130 | Registered Nurse | Interviewed regarding care plan completeness. |
| Staff #103 | Licensed Practical Nurse | Interviewed regarding enteral feeding and PICC line medication administration. |
Inspection Report — Mar 11, 2021
Routine
Date: Mar 11, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, resident care, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, incomplete PASARR screenings, inadequate care planning for depression and dietary preferences, failure to report and investigate an injury of unknown origin, incomplete monitoring of psychotropic medication side effects and behaviors, improper medication storage, incomplete nurse staffing postings, inadequate infection control practices including PPE use and COVID-19 testing, and failure to maintain social distancing during communal dining.
Deficiencies (16)
Failure to obtain informed consent for psychotropic medications for residents #58, #74, and #106 prior to administration and failure to correctly identify medication classification on consent forms.
Failure to timely report and thoroughly investigate an injury of unknown origin for resident #78, including failure to notify State Agency, Adult Protective Services, and Ombudsman.
Failure to complete PASARR level 1 screenings for residents #6 and #38 and failure to update PASARR for resident #104 after 30 days.
Failure to develop care plans addressing depression and antidepressant medication for resident #74 and failure to develop care plan addressing Jewish dietary preferences for resident #16.
Failure to have a physician order for hospice care and initial evaluation for resident #16.
Failure to thoroughly address and implement interventions for a fall for resident #131, including absence of floor mats and inadequate supervision.
Failure to have a physician order for oxygen use for resident #358 despite resident receiving oxygen therapy.
Failure to consistently post complete nurse staffing information including clinical staff numbers, scheduled hours, and resident census.
Failure to act timely on pharmacist medication regimen review recommendations for resident #74 regarding medication consents.
Failure to monitor and document side effects and targeted behaviors for psychotropic medications for residents #58, #74, and #78.
Failure to ensure expired medications and glucose test strips were removed and medications stored at proper temperature.
Failure to accommodate resident #16's Jewish dietary preferences including no pork and no dairy with meat.
Failure to maintain quaternary ammonium sanitizing solution at required concentration levels in kitchen sanitation buckets.
Failure to implement infection prevention and control measures including social distancing during communal dining, incomplete staff COVID-19 screening documentation, improper PPE donning and doffing, and incomplete cleaning of eye protection.
Failure to test two staff members (#107 and #212) for COVID-19 at the required twice weekly frequency during outbreak status.
Failure to tie gowns at the waist during COVID-19 testing, increasing infection control risk.
Report Facts
Morse Fall Scale score: 80
Morse Fall Scale score: 15
BIMS score: 10
BIMS score: 7
BIMS score: 13
BIMS score: 0
BIMS score: 5
Quaternary ammonium concentration: 100
Quaternary ammonium concentration: 200
COVID-19 staff testing missing: 2
Nurse staffing postings missing: 5
Nurse staffing postings missing clinical staff info: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #51 | Director of Nursing | Interviewed regarding medication consents, monitoring, infection control, and COVID-19 testing |
| Staff #216 | Administrator | Interviewed regarding communal dining, nurse staffing postings, sanitizing solution, and COVID-19 testing |
| Staff #217 | Assistant Administrator | Interviewed regarding nurse staffing postings, sanitizing solution, and COVID-19 testing |
| Staff #143 | Infection Preventionist | Interviewed regarding infection control, PPE, and COVID-19 testing |
| Staff #124 | Dietician | Interviewed regarding dietary assessments and resident #16 preferences |
| Staff #173 | Kitchen Manager | Interviewed regarding dietary preferences and sanitizing solution |
| Staff #180 | Licensed Practical Nurse | Interviewed regarding psychotropic medication monitoring |
| Staff #171 | Licensed Practical Nurse | Interviewed regarding medication regimen reviews and monitoring |
| Staff #96 | Licensed Practical Nurse | Interviewed regarding fall incident and reporting |
| Staff #189 | Licensed Practical Nurse | Interviewed regarding fall incident investigation |
| Staff #90 | Certified Nursing Assistant | Interviewed regarding fall incident |
| Staff #212 | Certified Nursing Assistant | Interviewed regarding fall incident and COVID-19 testing |
| Staff #81 | Licensed Practical Nurse | Interviewed regarding dietary preferences and fall prevention |
| Staff #125 | Certified Nursing Assistant | Interviewed regarding fall prevention |
| Staff #139 | Licensed Practical Nurse | Interviewed regarding medication storage |
| Staff #15 | Licensed Practical Nurse | Interviewed regarding oxygen order |
| Staff #95 | Certified Nursing Assistant | Interviewed regarding PPE donning and COVID-19 testing |
| Staff #47 | Licensed Practical Nurse | Interviewed regarding COVID-19 testing |
| Staff #1 | Certified Nursing Assistant | Interviewed regarding COVID-19 testing |
Report
Report
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