Inspection Reports for
Sandstone of Tucson

The complaint investigation substantiated that Resident #33 physically struck Resident #7, with staff intervening to separate the residents. The allegation of resident-to-resident abuse was verified by the facility. Resident #7 was moved to another room for safety, and behavioral health interventions were initiated for Resident #33.

The facility failed to protect Resident #7 from verbal and physical abuse by Resident #33, resulting in verified resident-to-resident abuse. The investigation included clinical record reviews, interviews, and observations, confirming the incident and subsequent interventions including relocation and behavioral health support.

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.

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.

The complaint investigation was substantiated. Resident #200 was physically abused by resident #300 using an electric wheelchair, causing a 3x1 abrasion. Resident #400 reported abuse by staff member staff #2, who stepped on his foot causing broken toes. The facility substantiated the abuse and took corrective actions including termination of staff #2 and reporting to the board of nursing.

The facility failed to protect resident #200 from physical abuse by resident #300, resulting in a 3x1 inch abrasion on resident #200's leg. Additionally, resident #400 was subjected to physical abuse by staff member staff #2, who was found to have stepped on the resident's foot causing broken toes. Staff #2 was terminated and reported to the board of nursing.

The complaint investigation verified abuse between Resident #1 and Resident #2, and between Resident #5 and Resident #6. Resident #1 physically assaulted Resident #2 and a CNA; Resident #5 struck Resident #6 after an altercation involving a wheelchair. Both incidents were reported to police and family, and appropriate actions such as resident separation and police involvement were taken.

The facility failed to protect the rights of 2 of 8 sampled residents from abuse by other residents, resulting in physical altercations and injuries. The incidents were verified by the facility and involved police notification and resident separation.

Complaint investigation citing 3 deficiencies related to abuse, neglect, and failure to report allegations.

The complaint investigation involved an incident on August 21, 2025, where Resident #4 threatened Resident #2 and attempted to hit him. The facility delayed reporting the incident to state agencies and failed to implement immediate safety measures such as increased monitoring, 1:1 supervision, or immediate room change. The allegation was substantiated by witness statements and facility review.

The facility failed to protect residents from abuse by not timely reporting a resident-to-resident altercation, not updating care plans, not increasing monitoring or supervision after the incident, and delaying room changes. The investigation verified the abuse allegation and identified deficiencies in policy implementation and reporting.

Complaint investigation citing 4 deficiencies related to abuse reporting, protection from abuse, and administrator responsibilities.

The complaint investigation substantiated abuse allegations between residents #77 and #76, and found failure to report and investigate an incident involving residents #69 and #81. The facility did not report the July 12, 2025 incident involving residents #69 and #81 to the State Agency and failed to conduct an investigation. Staff interviews confirmed inadequate responses to incidents and lack of timely reporting.

The facility failed to protect residents from abuse by other residents, including physical aggression and verbal threats. Additionally, the facility failed to timely report an allegation of abuse to the State Agency and did not conduct a proper investigation into the reported incidents. Staff responses to incidents were inadequate, and training on de-escalation was ongoing.

The complaint investigation found substantiated incidents of abuse and neglect involving residents #1, #2, #3, #4, and #5. Physical aggression between residents was documented, including hitting and slapping. Resident #5 sustained a facility-acquired thermal burn from hot coffee due to lack of proper supervision and safety interventions.

The facility failed to ensure residents were free from abuse and neglect, resulting in actual harm to a few residents. Multiple incidents of physical aggression between residents were documented, including one resident sustaining a burn injury from hot coffee due to inadequate supervision and safety measures.

Complaint investigation citing 2 deficiencies related to abuse and care planning.

Complaint survey citing 1 deficiency related to abuse, neglect, or exploitation allegations.

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.

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.

Complaint survey citing 2 deficiencies related to unnecessary drug administration and care planning.

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.

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.

Investigation citing 1 deficiency related to ensuring residents are free from abuse.

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.

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.

Complaint investigation citing 1 deficiency related to abuse prevention.

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.

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.

Investigation citing 2 deficiencies related to accident prevention and facility premises safety.

The complaint investigation found that resident #1, considered low risk for elopement, was able to leave the secured BHU unit on September 20, 2024, after a kitchen staff member let him out. Staff attempted to redirect the resident but were unsuccessful. Police and the resident's cousin were contacted to assist. The facility lacked a policy for security doors, and staff interviews confirmed procedural lapses.

The facility failed to ensure adequate supervision and security to prevent resident #1 from eloping the secured BHU unit on September 20, 2024. Staff allowed the resident to exit the unit without proper authorization, resulting in the resident leaving the facility and requiring police and family intervention. The facility lacked a policy for security doors.

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 notices, inadequate prevention of resident-to-resident abuse, untimely PASARR referrals, lack of resident participation in care planning, medication administration errors exceeding acceptable rates, expired medications and supplies accessible, inadequate qualifications of the activities director, unsafe medication storage practices, and food safety concerns including improper food temperatures and unsanitary resident refrigerators.

The investigation was unsubstantiated for elopement after the resident left the facility on his own accord. The facility attempted to contact the resident's power of attorney, but the phone number was no longer in service. Police and Adult Protective Services were notified.

The facility failed to ensure that resident #10, identified as an elopement risk, did not leave the facility unattended. Despite care plans and risk assessments indicating moderate risk, the resident was found outside unsupervised and eventually left the premises without authorization. The facility's monitoring and supervision practices, including reception desk coverage and resident tracking, were found inadequate.

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.

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.

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.

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.

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.

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.

The facility failed to ensure informed consent for psychotropic medications was obtained timely for multiple residents, failed to report and investigate an injury of unknown origin thoroughly, failed to complete PASARR screenings timely, failed to develop care plans addressing depression and dietary preferences, failed to have a physician order for hospice care, failed to implement fall prevention interventions fully, failed to have an oxygen order for a resident receiving oxygen, failed to post complete nurse staffing information, failed to act timely on pharmacist medication regimen review recommendations, failed to monitor psychotropic medication side effects and target behaviors consistently, failed to maintain medication storage standards, failed to accommodate dietary preferences, failed to maintain proper sanitizing solution levels, failed to ensure staff COVID-19 testing compliance, and failed to implement infection control measures including proper PPE use and social distancing during communal dining.