Handmaker Home for the Aging: Admin Appointment Failure - AZ
The inspection, completed September 12, 2025, identified a single deficiency, but it reached into two distinct failures: a paperwork trail that raised serious questions about whether the assistant administrator was ever legitimately installed in her position, and a buried abuse report that the facility never fully investigated and never reported to the state.
The person at the center of both findings was staff #103, listed on the facility's own staff roster as the Assistant Administrator. She carried that title on her business card. She was named in a July 30, 2025 letter, signed by the licensed nursing home administrator, as the individual accountable for the facility whenever the administrator was not on the premises. That letter cited Arizona Administrative Code by section number. It had the look of official designation.
What it did not have was any record of the governing board appointing her to the role.
Inspectors pulled the personnel file. The job description for the assistant administrator position was dated September 1, 2023. Staff #103 had signed it on September 13, 2023. The line for CEO approval was blank. Someone had added a handwritten line for human resources, and staff #103 had signed that line too, dating it the same day. The approval, in other words, came from the person being approved.
Her resume told its own story. Staff #103 had worked at the facility in a series of roles: receptionist, marketing representative, marketing and admissions coordinator. She moved into the assistant administrator title in September 2024. Before her time at Handmaker, she had spent roughly 24 years self-employed, training horses and giving riding lessons. Her education listed attendance at a community college from 1978 to 1980, with no degree noted. The resume contained no licenses. No certifications.
None of that, on its own, is disqualifying in every context. But the governing board of a licensed nursing facility is required to formally appoint the person who steps into administrative authority in the administrator's absence. There was no evidence that had ever happened.
When inspectors sat down with staff #103 and the licensed administrator, staff #110, on September 11, the administrator said he was not aware that the assistant administrator had to be appointed by the governing board. He said the facility had no policy on the subject. He identified no risk in the arrangement.
That conversation happened the day after a certified nursing assistant had told inspectors something that reframed everything about how authority was being exercised in that building.
The CNA, staff #101, was interviewed on September 10. She described reporting an incident of abuse to two people: the Assistant Director of Nursing, staff #104, and the Assistant Administrator, staff #103. The abuse had occurred in the behavioral unit, involving residents. What the CNA said she was told in response was direct: let it go. Stop escalating it. The residents involved were in the behavioral unit, and they would forget about it.
Inspectors found that the verbal abuse and intimidation described in the initial report had continued after that conversation. No thorough investigation appeared in the facility's documentation. No report to the state agency was found.
A registered nurse, staff #108, was interviewed the following morning. She described the proper protocol clearly: if resident-to-resident abuse occurred, she would separate the residents, check for injuries, ensure their safety, and then report to the ADON, the Assistant Administrator, and the Administrator. She named all three by first name and title. She said those individuals would conduct investigations and make sure the right notifications happened.
That is what the system was supposed to look like. What the CNA described was the system being told, by two of those same people, to stand down.
The connection between the two failures is not incidental. The assistant administrator was designated, in writing, as the person accountable for the facility in the administrator's absence. She was named in official correspondence citing state code. Staff throughout the building knew her title and her role. A nurse described her as one of three people responsible for investigating abuse. And yet her appointment to that position had never been ratified by anyone with actual authority to grant it. The CEO approval line on her job description had been left blank for two years.
What that means, practically, is that the person exercising administrative authority over abuse investigations, over staffing decisions, over the day-to-day operation of the facility when the licensed administrator was elsewhere, may have been doing so without the formal sanction of the body legally responsible for the facility's governance.
The administrator's response to that finding was that he hadn't known the board needed to be involved. The facility had no policy requiring it. No risk was identified.
The CNA who reported the abuse did what she was supposed to do. She took the incident up the chain. She told the Assistant Director of Nursing. She told the Assistant Administrator. And she was told, by both of them, that the residents in the behavioral unit would forget what had happened, and that she should too.
The verbal abuse and intimidation, inspectors found, did not stop.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Handmaker Home For the Aging from 2025-09-12 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
HANDMAKER HOME FOR THE AGING in TUCSON, AZ was cited for violations during a health inspection on September 12, 2025.
The person at the center of both findings was staff #103, listed on the facility's own staff roster as the Assistant Administrator.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.