Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sandstone Estates Rehab Centre during CMS and state inspections, most recent first.
The facility failed to maintain required RN coverage for at least 8 consecutive hours daily, 7 days a week, as shown by staffing schedules and time-clock records with no RNs documented on multiple days and day shifts while the census remained above 50 residents. Staff postings and punch details revealed repeated gaps in RN presence on specific dates and during daytime hours. The DON acknowledged that RN staffing levels did not meet expectations, and an RN reported that RN staffing had declined due to census changes, with large, overwhelming assignments and newly hired RNs resigning because of reduced work hours.
Surveyors found that kitchen dry storage contained multiple open packages of seasonings, gravies, and breadcrumbs that were sealed only with binder clips and lacked required opened-date labeling. Staff interviews confirmed that facility policy requires dry food items to be dated upon delivery, labeled with an open date when first used, and stored in sealed containers or Ziploc bags. The dietary manager acknowledged that the facility had previously used binder clips on opened items but that this no longer met current expectations, and that undated, improperly sealed food items were inconsistent with the facility’s written food receiving and storage policies.
The facility failed to ensure accurate and updated Level I PASRR screenings for two residents with documented mental health diagnoses and psychotropic medication use. For one resident with schizoaffective disorder and anxiety, the Level I PASRR did not reflect the schizophrenia diagnosis despite its presence in the record and care plan, and the Social Services Director acknowledged the omission without knowing why it occurred. For another resident with anxiety, bipolar disorder with psychotic features, and depression, the Level I PASRR indicated no mental illness, symptoms, psychiatric history, or psychotropic medications, even though the MDS, care plans, and multiple psychotropic orders documented severe cognitive impairment, moderate depression, social isolation, and extensive use of psychotropic, antianxiety, and antidepressant medications. The Social Services Director reported no formal PASRR training and difficulty using the PASRR submission website, while the DON confirmed there was no in-house PASRR training, identified inaccurate PASRR completion, and noted the absence of a Level II PASRR despite diagnoses that would have warranted Level II submission under facility policy and state review expectations.
A resident with major depressive disorder and intact cognition was admitted on antidepressant and antipsychotic medications, with an order for a behavioral health referral and a care plan specifying counseling by a mental health professional. Despite this, there was no documentation that psychiatric or psychological services were ever provided, no consent for treatment, and no follow-up on the referral order in the medical record. The resident reported being in a poor mental state, struggling with the transition from constant family support to facility restrictions, and waiting for therapy that had been discussed but never initiated. A CNA and an LPN were unaware of any mental health services provided, the social services director confirmed the absence of counseling documentation, and the DON acknowledged that the behavioral health order was not carried out, contrary to facility policies on implementing physician orders and comprehensive care planning.
A resident with diabetes, neuropathy, gait abnormality, and a history of falls was admitted with insurance authorization for skilled rehab and initially received PT for significant lower extremity weakness and instability. PT documented ongoing needs and unmet goals for strength and ambulation but discharged the resident while the resident still required supervision for walking and had not met all mobility goals, and no care plan, MD order, CNA task log, or restorative/functional maintenance program was created to implement the recommended staff‑assisted walking program. Subsequent MD notes described continued weakness and functional decline and incorrectly attributed the end of therapy to insurance, even though coverage remained in place. When the resident later requested more PT, there was a delay in entering the therapy order, and a new PT evaluation found a decline in mobility, recommended a right lower extremity brace and a restorative or functional maintenance program, and verbally asked CNAs to walk with the resident; however, there was no documented MD order or insurance communication for the brace, no formal restorative program, and no documented walking plan, leaving the resident without the specialized rehab and restorative services identified as necessary to maintain function.
A resident with severe cognitive impairment and a history of wandering and agitation was identified as an elopement risk, yet was not placed on a secured unit or provided with sufficient supervision. Despite staff awareness of the resident's behaviors and repeated expressions of wanting to leave, the resident was able to exit the facility unsupervised and was later found at a nearby bus stop. The facility's policy required at-risk residents to be accompanied when leaving, but this was not followed, resulting in a failure to prevent the elopement.
A resident's medications were misappropriated by an LPN who manipulated prescription forms to divert narcotics. Despite previous disciplinary actions and a performance improvement plan, the LPN continued to falsify prescriptions, leading to termination after an investigation substantiated the diversion. The facility reported the incident to the state, revealing a significant lapse in medication management.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The deficiency involves the facility’s failure to provide RN coverage for at least 8 consecutive hours a day, 7 days a week, as required by its Nursing Administration Policy dated May 1, 2024. Review of staff posting sheets from February 15, 2026, through March 17, 2026, showed that the RN sections were blank on multiple days when the census ranged from 51 to 64 residents, specifically on February 26, March 1, March 8, and March 15, 2026. Punch detail reports for RNs during the same period showed no time-clock data for those dates for multiple RNs, indicating that no RNs were on duty. Additional review of staff postings revealed that the RN sections for the 6:00 AM to 6:30 PM shift were blank on February 28 and March 7, 2026, when the census was 65 and 66 residents, respectively, and punch detail reports showed no RN time entries from 6:00 AM to 6:00 PM on February 24, February 27, February 28, and March 7, 2026. In interviews, the DON acknowledged that the level of RN staffing did not meet her expectations and stated that the absence of an RN increased the risk of missing early interventions that could prevent rehospitalizations or emergency room visits. An RN reported that RN staffing had decreased since May 2025 due to a lower census and described experiencing large and overwhelming resident assignments. The RN also stated that although some RNs had been hired, they later resigned because of a decreased number of working hours. These documented staffing patterns and staff statements demonstrate that the facility did not ensure continuous RN coverage for at least 8 consecutive hours each day, 7 days a week, as required by facility policy.
Improper Labeling and Sealing of Open Dry Food Items in Kitchen Storage
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices in the kitchen dry storage area. During an observation with dietary and environmental services staff, multiple open original packages of taco seasoning, brown gravy, chicken gravy, turkey gravy, and breadcrumbs were found sealed only with binder clips and lacking any labels indicating an opened date. These items were not placed in sealable containers or bags, and there was no documentation of opened or use-by dates visible to staff, contrary to the expectations described by facility staff and written policies. In interviews, the dietary director/maintenance director/environmental services director and a dietary cook stated that facility expectations require opened dry storage items to be labeled with an open date and, as applicable, a use-by date, and to be stored in a sealable container or package. The dietary manager further explained that unopened items are expected to be dated with the delivery date, and once opened, items should be placed in a Ziploc bag and labeled with both the delivered and opened dates. The dietary manager acknowledged that the facility had previously used binder clips on opened packages based on earlier guidance but stated that this practice had been changed, and that opened food packages without dates and not sealed appropriately were not within facility expectations due to the risk of using expired food and attracting pests. Facility policies titled “Food Receiving and Storage” and “Storage Labeling and Dating” require that foods be received and stored in compliance with safe food handling practices, and that opened products in dry storage be labeled with their received and open dates.
Inaccurate and Incomplete PASRR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Level I PASRR screenings were accurately completed and updated for two residents with documented mental health diagnoses and psychotropic medication use. For one resident with Parkinson’s disease, schizoaffective disorder, and anxiety disorder, the Level I PASRR dated May 6, 2024 indicated that a Level II PASRR referral was not necessary. However, the section of the Level I PASRR that asked whether the resident had a diagnosis of schizoaffective disorder was not checked, despite the resident’s documented diagnosis and use of psychotropic medications including bupropion, trazodone, and Depakote. The resident’s care plan was later revised to include a focus on psychosocial well-being related to schizophrenia, and a quarterly MDS showed intact cognition with a BIMS score of 15. During an interview, the Social Services Director confirmed that this resident had a PASRR I in the record and acknowledged that the schizophrenia diagnosis was not listed on the form. He stated he was unsure why the diagnosis was not included and indicated that he would have expected the schizophrenia diagnosis to be identified on the PASRR I if the resident had that diagnosis. This reflects that the documented mental health condition and related psychotropic medication use were not accurately captured on the PASRR screening, despite being present in the clinical record and care plan. For the second resident, who had diagnoses including anxiety disorder, bipolar disorder (including a current manic episode with psychotic features), depression, and generalized anxiety disorder, the Level I PASRR dated December 14, 2023 showed no evidence of mental illness, no symptoms, no history of psychiatric treatment, and no psychotropic medications. This conflicted with the admission MDS, which documented severe cognitive impairment (BIMS score of 5), multiple depressive symptoms over the prior 14 days with a severity score of 12 indicating moderate depression, social isolation, and diagnoses of anxiety disorder, depression, and bipolar disorder. The MDS also documented that the resident had been taking antianxiety medications, and the care plan included focuses on risk for adverse reactions to psychotropic medications, mood problems related to depression, bipolar disorder, and anxiety, and the use of behavioral health consults as needed. The resident’s record further showed multiple psychotropic medication orders over time, including buspirone, trazodone, lorazepam, suvorexant, doxepin, and bupropion, with indications such as anxiety, depression, insomnia, agitation, restlessness, hallucinations, and anhedonia. Care plan focuses documented use of psychotropic, antianxiety, and antidepressant medications related to bipolar disorder, anxiety disorder, and depression, as well as limited activity involvement related to anxiety and depression. Despite this, the PASRR form for this resident contained no evidence of diagnoses or medications. In interviews, the Social Services Director stated he had never been formally trained on the PASRR process, was not familiar with what a completed PASRR form should look like, and had difficulty using the website he believed was for PASRR submissions. He acknowledged that the resident’s diagnoses and medications would have been triggers for a Level II PASRR submission and was unsure how to address inaccurate PASRR information. The DON stated that the PASRR process involved receiving a form from the hospital to ensure appropriate placement and treatment, and that if a resident stayed beyond 30 days and had an appropriate diagnosis, a Level II form should be sent to the state agency. She reported there was no in-house PASRR training and that additional training could be requested for the Social Services Director. She also stated she had only learned that a corporate contact in another state handled the facility’s PASRR process and was unsure if that person knew Arizona regulations. Regarding the second resident, the DON stated that the diagnoses of anxiety, depression, bipolar disorder, and bipolar disorder with psychotic features would have been appropriate for a Level II PASRR submission and identified inaccurate completion of PASRR sections requiring information on exemptions, mental illness diagnoses, symptoms, psychiatric history, and medications. She confirmed there was no evidence of a Level II PASRR for this resident and stated that not submitting a Level II form for a resident who could benefit from state agency review could leave the resident at a disadvantage in receiving appropriate review of behavioral health interventions. The facility’s PASRR policy required validation that each resident is screened for mental disorder or intellectual disability before admission, referral of residents with newly evident or possible mental disorder or intellectual disability to the state authority, and incorporation of Level II determinations and recommendations into assessments and care plans, which was not followed in these cases.
Failure to Implement Ordered Behavioral Health Services for Depressed Resident
Penalty
Summary
The facility failed to provide and implement necessary behavioral health services for a resident with identified mental health needs, despite physician orders and care plan interventions. The resident was admitted with major depressive disorder, adult failure to thrive, cognitive communication deficit, and a need for assistance with personal care. Medication orders included aripiprazole for mood stabilization and mirtazapine for depression. An order was entered for a referral for behavioral health services for psychiatric and psychological evaluation and treatment, and the care plan documented that the resident used antidepressant and psychotropic medications related to depression and was to receive counseling by a mental health professional. An admission MDS showed the resident had intact cognition with a BIMS score of 15 and reported feeling down, depressed, or hopeless on multiple days within the assessment period, with documented depression and use of antipsychotic and antidepressant medications. However, there was no evidence in the electronic health record that the resident ever received the ordered behavioral health or counseling services. Progress notes contained no documentation of counseling, consent for treatment, or follow-up on the behavioral health referral order. In interviews, the resident reported being in a poor mental state upon admission, experiencing a difficult transition from constant family support to facility restrictions, and waiting for therapy services that had been discussed with the social services director but never initiated or updated. A CNA and an LPN both stated they were unaware whether the resident had received mental health services. The social services director confirmed the resident had a diagnosis of major depressive disorder, a care plan intervention to see a counselor, and an order for counseling services, but found no documentation of services or progress notes. The DON acknowledged that an order for behavioral health services had been obtained and that there was no evidence of services provided, no signed consent, and no follow-up on the order, stating that the order “fell through the cracks,” despite facility policies requiring that physician orders be implemented and incorporated into the care plan.
Failure to Provide and Coordinate Specialized Rehab and Restorative Services for Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to provide and coordinate specialized rehabilitative services, including PT and related supports, for a resident with significant mobility impairments so the resident could attain and maintain the highest practicable level of function. The resident was admitted with type 2 diabetes with neuropathy, unsteadiness on feet, abnormal gait and mobility, dementia, and a history of falls. An insurance referral authorized skilled services through mid‑April, and the initial PT evaluation on January 8 identified right lower extremity ataxia, decreased strength, knee buckling, decreased endurance, and a recent history of four falls. PT established a plan for therapy five times per week for 60 days, with goals to improve strength, gait, transfers, and safety awareness. Early assessments and the admission MDS documented impaired lower extremity ROM and the need for assistance with bed mobility, transfers, and ambulation. PT progress documentation through January 22 showed the resident was making consistent progress but had not yet met all long‑term goals, particularly for independent ambulation and stair negotiation, and still had balance, strength, coordination, and safety deficits. On January 27, PT notes showed the resident required supervision and cueing for gait and transfers, and the physician documented ongoing bilateral lower extremity weakness and gait instability with a plan to continue inpatient PT. However, on January 28, PT discharged the resident from therapy, stating that most functional goals were met and maximum benefit achieved, even though the discharge summary documented that lower extremity strength goals and long‑term ambulation and stair goals were not met and that the resident still required supervision for walking 250 feet with a walker. The discharge note recommended daily ambulation with staff and use of the therapy gym bike, but there was no evidence of a corresponding care plan, physician order, CNA task log, or restorative/functional maintenance program to implement a structured walking program or to ensure staff supervision for ambulation. After discharge from PT, late entry physician notes in February recorded that the resident remained weak with functional decline and was off therapy “per the insurance provider,” despite other documentation from the DOR and business office that insurance coverage for skilled therapy remained in effect. The care plan was revised in February to address transfer, toilet use, and bathing assistance but did not address walking. In early March, the resident requested to resume PT, and the physician documented placing an order, but no therapy order appeared in the record until March 16. A PT evaluation on March 17, designated as “evaluation only,” found a decline in functional mobility since the January discharge, with the resident now needing verbal cueing for bed mobility, supervision for transfers, and standby assistance for walking 20 feet. PT attributed some decline to lack of ambulation without staff assistance, while also noting the resident had been consistently using the therapy gym for weight lifting and biking. The evaluation recommended a right lower extremity brace/orthotic and a restorative or functional maintenance program, and PT reported verbally telling CNAs to walk with the resident twice daily with supervision. However, there was no evidence in the record of a physician order or insurance communication for the brace, no documented restorative or functional maintenance program, and no care plan or CNA task documentation for a walking program. Interviews with the resident, CNAs, therapy, and nursing leadership confirmed that CNAs had not received clear PT “clearance” or training to walk with the resident, that the facility had no designated restorative staff, and that recommended orthotic and walking interventions were not formally ordered, coordinated, or care‑planned, resulting in the resident not receiving the specialized rehabilitative services identified as needed by PT and the facility’s own policies.
Failure to Provide Adequate Supervision for Resident at Risk of Elopement
Penalty
Summary
A resident with a history of cerebral infarction, encephalopathy, stimulant abuse, and schizophrenia was admitted to the facility with severely impaired cognition, as indicated by a BIMS score of 3. The resident was identified as an elopement risk and exhibited behaviors such as wandering, agitation, rejection of care, and attempts to leave the facility. Multiple clinical notes documented frequent wandering, unsteadiness, agitation, and verbal expressions of wanting to leave. The care plan and wander risk assessments recognized the resident's risk for elopement, but despite these documented risks, the resident was not placed on a secured unit prior to the incident. Staff interviews revealed that the resident was known to be a 'runner' and was closely watched by staff, but there were lapses in supervision. On the day of the incident, the resident was highly agitated and expressed a desire to leave. The resident's wheelchair was later found outside the facility's front doors, and a search determined that the resident had eloped and was found at a nearby bus stop. The receptionist, responsible for monitoring the front door, did not observe the resident leaving, and the facility's policy required that at-risk residents be accompanied by staff or a responsible party when leaving the grounds. Despite staff awareness of the resident's behaviors and risk factors, the resident was able to exit the facility unsupervised. The facility did not implement additional interventions, such as transferring the resident to a secured unit, prior to the elopement, even though staff had discussed this option. The deficiency resulted from the failure to provide adequate supervision and to follow established policies for residents at risk of elopement.
Misappropriation of Resident Medications by LPN
Penalty
Summary
The facility failed to protect a resident from the misappropriation of medications, specifically involving the actions of an LPN. The resident, who had been admitted with conditions including Parkinson's disease, major depressive disorder, post-traumatic stress disorder, and heart failure, had prescriptions for narcotics such as Oxycodone and Morphine that were improperly managed. The LPN placed and discontinued these orders on the same day, raising concerns about the handling of narcotics. The LPN had a history of disciplinary actions related to narcotic management, including a probationary period for failing to follow procedures when dispensing narcotics. Despite a performance improvement plan requiring oversight and regular follow-ups, these measures were not documented as completed. The LPN was later terminated following an investigation that substantiated narcotic diversion, where the LPN was found to have falsified prescriptions and diverted medications. The facility's investigation revealed that the LPN manipulated prescription forms to obtain narcotics fraudulently. This involved using an old prescription form and overlaying new patient information to create false prescriptions. The facility identified over 34 instances of such fraudulent activity, with the LPN receiving and then discontinuing the medications to cover up the orders. The facility reported the incident to the state and terminated the LPN, but the deficiency highlighted a significant lapse in safeguarding resident medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tucson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Devon Gables Rehabilitation Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Sabino Canyon Rehabilitation & Care Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Pueblo Springs Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Handmaker Home For The Aging | 1.2 mi | ★★★★★ | 12 | 1 |
| Foothills Rehabilitation Center | 1.2 mi | ★★★★★ | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sandstone Estates Rehab Centre.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.