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Complaint Investigation

Sandstone Of Tucson Rehab Centre

Inspection Date: November 20, 2025
Total Violations 2
Facility ID 035099
Location TUCSON, AZ
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Inspection Findings

F-Tag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

-Resident #40 was initially admitted to the facility on [DATE REDACTED] with diagnoses that included altered mental status, type 2 diabetes hypertension, with additional diagnoses that included dementia onset dated November 6, 2021, anxiety disorder, onset March 16, 2022, and schizophrenia onset March 30, 2022.

A behavior care plan revealed that Resident #40 has potential to be verbally aggressive related to ineffective coping skills.

An order summary revealed the following: Ativan tablet for anxiety as evidenced by restlessness Quetiapine Fumarate Tablet for schizophrenia as evidenced by delusions.

A June 2022 MAR revealed that all medications were administered as ordered, and medication monitoring was completed as ordered.

An IDT Note dated October 27, 2021 revealed that Resident #40 was verbally aggressive towards another resident, no interventions at this time.

A behavior note dated February 14, 2022 revealed that Resident #40 started screaming in the hallway, threatening to slap the shit out of you and to kick CNA's ass.

A physician note dated May 9, 2022 revealed that in the past 30 days the resident has shown some mood swings.

A behavioral health follow-up progress note dated May 9, 2022, revealed that the resident reports that he gets agitated when people are in his room or say something.

A practitioner note dated May 12, 2022 revealed that per nursing the patient is exhibiting worsening aggressive behavior towards other residents, plan was to increase Seroquel for schizophrenia as evidenced by delusions and worsening aggressive behavior.

Review of the care plan revealed no evidence of inter

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

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sandstone of Tucson Rehab Centre

2900 East Milber Street Tucson, AZ 85714

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)

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F-Tag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

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

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

2022 and the incident submission documentation dated October 24, 2022. Staff #93 stated that the incident submission had not transpired within the 2-hour timeframe and that this did not meet her expectation. Staff # 93 stated that potential risk would include resident safety if the report was not made timely.An interview was conducted on September 25, 2025 with the administrator, staff #38. Staff #38 stated that an incident of abuse is to be reported immediately but within 2 hours to the SA (state agency). She further stated that all parties involved would be separated, notifications would transpire and that corrective action would be implemented. Staff #38 stated that a delay in reporting could impact the investigation and safety of the resident.A review of the facility policy titled Abuse and Neglect with an adopted date of May 1, 2024 revealed that notification to the state agencies that an investigation is being initiated is to immediately follow interventions for the resident's safety post suspected incident. The policy further stipulates that allegations of abuse must be reported to appropriate state agencies immediately and not later than 2 hours after receiving the allegation of abuse.

Event ID:

Facility ID:

If continuation sheet

📋 Inspection Summary

SANDSTONE OF TUCSON REHAB CENTRE in TUCSON, AZ inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TUCSON, AZ, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SANDSTONE OF TUCSON REHAB CENTRE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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