Handmaker Home For The Aging

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

dementia unit. She stated she was made aware of incidents of verbal aggression between resident #1 and resident #2 after it happened; and, she reported it the DON, who had been gone roughly 10 days. The ADON further stated, at that time, she was told to have the psychiatrist see resident's #1 and #2.An

interview was conducted on September 11, 2025, at 11:37 AM, with the Administrator (staff #110), and the Assistant Administrator (staff #103). Both staffs (#110 and #103) stated that abuse was defined as sexual, verbal, financial, physical, exploitation, derogatory speech, belittling, yelling, intimidation, and having an aggressive tone. The assistant administrator stated that if a resident had cognitive issues or if something was witnessed on the dementia unit, it was still considered to be abuse. She stated she was aware of the incident on September 3, 2025 between resident #1 and resident #2; however, she stated that the only witness to the incident was another resident (#3) and resident #1 was interviewed by staff, resident #1 could not remember being hit. The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident ; and the only incident between resident #1 and #2 that the facility was aware of was the slapping incident on September 3, 2025.An interview with a CNA (staff #109) was conducted on September 12, 2025 at 9:29 AM. The CNA stated she was the 1:1 sitter assigned to resident #2, who was now very calm, relaxed, was not tense or agitated, and was smiling after she had moved to a different unit. In another interview with CNA (staff #101) conducted on September 12, 2025, at 1:45 PM, the CNA stated that resident #2 was transferred to another unit, resident #1 went to bed early and did not ask her to stay; and that, resident slept well. Review of the facility's policy on Abuse, Neglect, and Exploitation, dated July 2025 revealed that it was their policy to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Verbal abuse was defined as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. The policy also included that the facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents; and, the facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Handmaker Home for the Aging

2221 North Rosemont Boulevard Tucson, AZ 85712

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

if an incident was not witnessed, the facility investigates the incident first and then decide if the incident needed to be reported. The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident. The assistant administrator further stated stated that if staff witnessed any abuse or think that abuse was occurring, staff were to report the incident to their direct supervisor who would then report the allegation to her; and that, she would then notify the administrator (staff #110) of the incident. Further, the assistant administrator said that she and the administrator would report the allegation, complete a five-day investigation to the SA, and would also report to the local police, Adult Protective Services (APS), the Ombudsman, and to the resident's families. Review of the facility's policy on Abuse, Neglect, and Exploitation, dated July 2025 revealed that it was their policy to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Verbal abuse was defined as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.

Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. The policy also included that the facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents; and, the facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to increased supervision of

the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. The facility's policy also included that the facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The administrator will follow-up with government agencies, during business hours, to confirm the initial report was received, and to report

the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Handmaker Home for the Aging

2221 North Rosemont Boulevard Tucson, AZ 85712

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

considered to be abuse. She stated she was aware of the incident on September 3, 2025 between resident #1 and resident #2; however, she stated that the only witness to the incident was another resident (#3) and resident #1 was interviewed by staff, resident #1 could not remember being hit. Further, the assistant administrator said that the incident was determined to be not reportable; and that, if an incident was not witnessed, the facility investigates the incident first and then decide if the incident needed to be reported.

The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident ; and the only incident between resident #1 and #2 that the facility was aware of was the slapping incident on September 3, 2025. The assistant administrator further stated stated that if staff witnessed any abuse or think that abuse was occurring, staff were to report the incident to their direct supervisor who would then report the allegation to her; and that, she would then notify the administrator (staff #110) of the incident. Further, the assistant administrator said that she and the administrator would report the allegation, complete a five-day investigation to the SA, and would also report to the local police, Adult Protective Services (APS), the Ombudsman, and to the resident's families. The facility's policy on Abuse, Neglect, and Exploitation, dated July 2025, stated the facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The administrator will follow-up with government agencies, during business hours, to confirm the initial report was received, and to report

the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Handmaker Home for the Aging

2221 North Rosemont Boulevard Tucson, AZ 85712

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Director of Nursing (DON). However, the CNA said that depending on the severity of the abuse, such as resident slapping another, she would just report to the ADON or human resources and skip the floor nurse.

An interview was conducted with another CNA (staff #106) on September 10, 2025 at 5:04 PM, The CNA (staff #106) said that resident #1 has suffered from harm from the verbal and physical abuse by resident #2.

She stated staff in the unit were doing the best they could to keep both residents #1 and resident #2 separated from each other but it can be difficult at times. Further, the CNA said that when staff reported

these incidents to management, the management team did not listen, and nothing was done to address the behavior or resident #2.In another interview with the CNA (staff #101) conducted on September 10, 2025, at 8:21 PM. The CNA said that in the evening of September 10, 2025, the vice president of human resources (HR/staff #145), the assistant administrator (staff #103), the ADON (staff#104), and the human resources coordinator (HRC/staff #132), provided her with abuse education, and instructions to call the abuse hotline if she witness an incident of abuse. The CNA further stated that the HRC (staff #132) told her to go through the facility's chain of command and do not report the incident to the SA. In an interview with

the ADON (staff #104) conducted on September 11, 2025 at 11:09 AM, the ADON stated that yelling, swearing at, and taunting were considered as verbal abuse even if these behaviors happened in the dementia unit. She stated she was made aware of incidents of verbal aggression between resident #1 and resident #2 after it happened; and, she reported it the DON, who had been gone roughly 10 days. The ADON further stated, at that time, she was told to have the psychiatrist see resident's #1 and #2.An

interview was conducted on September 11, 2025, at 11:37 AM, with the Administrator (staff #110), and the Assistant Administrator (staff #103). Both staffs (#110 and #103) stated that abuse was defined as sexual, verbal, financial, physical, exploitation, derogatory speech, belittling, yelling, intimidation, and having an aggressive tone. The assistant administrator stated that if a resident had cognitive issues or if something was witnessed on the dementia unit, it was still considered to be abuse. She stated she was aware of the incident on September 3, 2025 between resident #1 and resident #2; however, she stated that the only witness to the incident was another resident (#3) and resident #1 was interviewed by staff, resident #1 could not remember being hit. Further, the assistant administrator said that the incident was determined to be not reportable; and that, if an incident was not witnessed, the facility investigates the incident first and then decide if the incident needed to be reported. The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident ; and the only incident between resident #1 and #2 that the facility was aware of was the slapping incident on September 3, 2025.The facility's policy on Abuse, Neglect, and Exploitation, dated July 2025, defines verbal abuse as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. It defines mental abuse as includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. It defines physical abuse as includes, but is not limited to hitting, slapping, punching, biting, and kicking. The policy states it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Handmaker Home for the Aging

2221 North Rosemont Boulevard Tucson, AZ 85712

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

exhibited and what the behavior was. She stated that the documentation in the MDS, would determine if there was a need for care planning. During the interview, a review of the clinical record was conducted with

the LPN who stated that there were verbal behaviors documented in the clinical record that should have been care planned. However, the LPN stated that the resident's care plan did not include the behaviors as a focus of care and had not been documented in the care plan. She stated that the resident had verbal behaviors and these should have been documented on the care plan. Further, the LPN stated that the risk for not documenting these in the care plan could impede behavior identification, de-escalation and continuance of the problem.An interview was conducted on September 11, 2025 at 11:09 A.M. with the assistant director of nursing (ADON/staff #104) who stated that if there was something identified on the MDS then it should be transferred to the care plan to address any concerns. A review of the clinical record was conducted by the ADON who stated that the clinical record documented the resident had identified verbal behaviors; but, behaviors were not care planned with interventions prior to the September 11, 2025.

She stated that the risk could include lack of clear communication to staff and to ensure that interventions were in place.An interview with the Assistant Administrator (staff #103) and the Administrator (staff #110) was conducted on September 11, 202 at 11:37 A.M. The Assistant Administer stated that the expectations were for the care plan to include a full detail of what services were being provided, resident profile, historical data, daily care needs, and the management of behavioral interventions. The Assistant Administrator reviewed the clinical record and stated that the MDS assessment for resident #2 identified the verbal behaviors at 4 to 6 days per week. However, a upon reviewing the resident's care plan she stated that resident's verbal behaviors had not been included as a focus of care and it should have been. Further,

the assistant administrator stated that the risk for not documenting the behaviors in the care plan could include staff not knowing what to watch for which could lead to an incident occurring.In an interview with Social Services (staff #242) conducted on September 11, 2025 at 2:25 P.M., staff #242 stated that part of her role regarding care plans included identifying the needs of the residents and talking to the MDS coordinator to enter those needs into the care plan. She stated that a variety of things get entered into the care plan to include psycho-social needs, depression, activities of daily living, behaviors and advanced directives. She stated that unless something was brought to her attention, she only reviews the resident notes on a quarterly basis; and, she was not aware of the behavioral notes for resident #2. Further, staff #242 stated that ideally these should have been noted in the care plan; and, there really would not be a risk as the behaviors had been documented elsewhere in the record, but could include a lack of not communicating appropriately.A review of the policy entitled Comprehensive Care Plans with a review date of September 11. 2025 revealed that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Handmaker Home for the Aging

2221 North Rosemont Boulevard Tucson, AZ 85712

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on interviews, facility documentation and postings, the facility failed to ensure the assistant administrator was duly appointed by the governing board. The deficient practice could contribute to actions, inactions or decisions regarding facility deficiencies, as related to attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident.Findings include:A review of the personnel file for the assistant administrator (staff #103) revealed a job description dated September 1,

1. 2023. The job description revealed that the position of an for assistant administrator was signed on

September 13, 2023 by staff #103. The approval line within the document noting CEO (chief executive officer) approval was blank. Further, a handwritten line had been added which noted HR (human resources) containing the signature of staff #103 and dated on September 13, 2023.Review of the resume for staff #103 revealed that from September 17, 2024 to current, staff #103 had the title of an Assistant Administrator/ Marketing/Admissions Director for the facility. It also included that from October 25, 2025 to September 16, 2024 staff #103 had a job title of Marketing/admission Coordinator for the facility.

Subsequent entries revealed a job title of Marketing Representative, and Receptionist for the facility. It was noted that staff #103 was self-employed from 1976 through 2000, training horses and giving riding lessons.

The educational component of the resume revealed attendance at a community college from 1978 to 1980, with no notated degree. No licenses or certifications were documented in the resume.A facility business card for staff #103 revealed a title of Assistant Administrator.The staff list provided by the facility noted staff #103 as the Assistant Administrator.Further review of the facility documentation revealed a letter dated July 30, 2025 noting that under the Arizona Administrative Code Resident R9-10-303, subsection (B)(3) staff #103, the assistant administrator, was designated as the individual who was present and accountable for the nursing care institution when the administrator was not present on the premises. The letter was signed by Licensed Nursing Home Administrator (staff #110).There was no evidence found in the facility documentation the Assistant Administrator (staff #103) was the qualified assistant administrator appointed by the facility's governing board.An interview was conducted on September 10, 2025 at 10:51 A.M. with a certified nursing assistant (CNA/staff #101) who stated that an incident of abuse had been reported to the Assistant Director of Nursing (ADON/staff #104) and to the Assistant Administrator (staff #103). The CNA stated that the incident was reported and the intruction from ADON and Assistant Administer was to let the incident go and to stop escalating it, as it involved residents in behavioral unit and that the residents would forget about it.

However, both verbal abuse and intimidation, per staff interviews and facility documentation continued after

the initial incident and no evidence of a thorough investigation or report to the state agency were observed

in the facility documentation.An interview was conducted on September 11, 2025 at 9:39 A.M with RN (registered nurse/ staff #108). The RN stated that if resident to resident abuse occurred, she would separate the residents, ensure that there were no injuries, make sure they are safe and then report to the ADON (staff #104), the Assistant Administrator (staff #103) and the Administrator (staff #110). Staff #108 identified the ADON, Assistant Administrator and Administrator by first name and title. The RN stated that

they would conduct the investigations and ensure that the proper notifications transpired.An interview was conducted on September 11, 2025 at 11:37 A.M. with staff #103 and staff #110. During the interview staff#103 identified herself as the Assistant Administrator. Staff #110 further stated that the facility did not have a policy for Assistant Administrator appointment, nor was he aware that the assistant administrator had to be appointed by the governing board. No risk was identified by staff #110.The facility did not have a policy for Assistant Administrator appointment.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet