Sandstone of Tucson Rehab Centre
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 189 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Special Focus Facility (under heightened CMS scrutiny)
- Abuse citation on record
- Low overall rating (2/5 stars)
- Above-median deficiencies (33 vs median 6.0)
Bottom 25% in AZ · Below recommended RN staffing · Best in SANDSTONE HEALTHCARE GROUP chain · $20,930 in fines · Special Focus Facility (CMS) · Abuse citation
What this means for your family
While some families report positive experiences with the therapy and nursing teams, the facility has a concerning pattern of communication failures and neglectful care. We strongly advise you to visit in person, observe the response time to call lights, and ask specifically how they handle medical emergencies and family notifications before making a decision.
Google Reviews
Google Reviews
189 reviews analyzed“Sandstone of Tucson (formerly Sapphire of Tucson) receives highly polarized feedback, with many families praising the nursing and therapy staff for their kindness and professionalism. However, a significant number of reviewers report severe issues, including poor communication, neglectful care, slow response times to call lights, and concerns regarding cleanliness and food quality. Families should be aware that while some have had positive experiences, there are recurring reports of serious lapses in patient safety and administrative responsiveness.”
Quality Themes
Tap a score for detailsStrengths
- Kind and attentive nursing and CNA staff
- Effective physical and occupational therapy
- Welcoming and professional front desk staff
- Supportive case management and social services
Concerns
- Poor communication and failure to return family phone calls (mentioned by 12 reviewers)
- Slow response times to call lights or neglectful care (mentioned by 10 reviewers)
- Poor food quality and failure to meet dietary needs (mentioned by 6 reviewers)
- Facility cleanliness and maintenance issues (mentioned by 5 reviewers)
Rating Trends
Tap a year to see what changed
Distribution
How They Respond to Reviews
This facility responds to some reviews.
Questions for Your Tour
- 1I noticed the management team is very active in responding to feedback online; how does the facility currently use family input to improve daily operations?
- 2Since the nursing and therapy teams are highly regarded, could you explain how the staff coordinates care between physical therapy and daily nursing needs?
- 3What specific steps are being taken to ensure consistent communication with family members, especially when we have questions about a loved one's care?
- 4How does the dining program manage specific dietary requirements and ensure meal quality is consistent for every resident?
- 5Could you describe the protocol for responding to call lights and how the team ensures resident needs are met promptly throughout the night?
- 6What is the routine for facility maintenance and cleanliness to ensure the resident rooms and common areas are always well-kept?
Personalized based on this facility's data
Key Review Excerpts
“The biggest problem I had was that I'm diabetic. The kitchen did not care. Fried fish for lunch on Friday with a pile of French fries or macaroni and cheese.”
“My father passed away at this facility, less than 48 hours after arriving... Once deceased, we were not notified for over 4 hours.”
“The Sandstone Team of doctors and nurses adjusted medications to get the right balance of safe behavior. Each time I visit, the staff (even the cleaners) are showing the residents kindness, patience, respect, and love.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
11
measures
4
measures
2
measures
Residents on antipsychotic medication
Residents with depression symptoms
Residents whose bladder or bowel control got worse
Residents on anti-anxiety or sleep medication
Residents vaccinated for pneumonia
Residents who lost too much weight
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility shows a concerning pattern of abuse and neglect complaints, with families filing 28 reports leading to federal investigations. The most frequent issues involve protection from abuse and neglect, accident prevention and safety, and care planning. While deficiencies appear corrected after discovery, the persistent nature of abuse-related complaints through 2026 suggests ongoing problems with resident protection and supervision that families should carefully evaluate before choosing this facility.
Feb 11, 2026Complaint3
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Jan 28, 2026Complaint7
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Jan 5, 2026Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Dec 11, 2025Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Nov 20, 2025Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Nov 19, 2025Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Federal Penalties
Fine
Apr 22, 2025
$20,930
State Inspection History
State Inspections
Source: AZ State Licensing Agency
Mar 24, 2026Other
Based on document reviews and interviews, failed to maintain, review, and update the Emergency Preparedness (EP) Plan annually. Failure to develop an emergency plan may cause harm to the patients and staff during an emergency and failure to ensure the EP plan was reviewed annually poses a potential risk that all required revisions to the plan will not be recognized and revised as needed.
Based on observation, it was determined that the facility failed to maintain the sprinkler heads and ensure that all parts of the sprinkler system were in accordance with the UL Listing. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the U.L. Listing of the sprinkler assembly, could allow heat and smoke to affect other areas of the building. This could cause harm to the staff and residents.
Based on observation and interview, the facility failed to provide corridor doors in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.6, 19.3.6.3, and 19.3.6.3.10. This deficient practice could affect approximately 38 of the 116 residents plus staff in the event of a fire. Â
Based on observation, it was determined that the facility failed to properly fill penetrations of the fire/smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the fire/ smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients and staff in the affected area at the time of a fire.
Based on observation, the facility failed to provide a protective guard on light bulbs located throughout the facility. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.Â
Feb 10, 2026Complaint
An onsite complaint survey was conducted on February 10, 2026 through February 11, 2026 for the following intakes: 00158101, 00158089, and 00158653. The following deficiencies were cited:
The facility failed to ensure an allegation of abuse for one resident (#4) was reported to the State Agency (SA) within the timeframe established by regulations. The deficient practice could lead to continued abuse of residents.
Based on review of the clinical record, interviews, and review of the facility’s policies and procedures, the facility failed to protect the rights of one resident (#6) to be free from abuse from another resident (#9). The deficient practice could lead to sustaining injuries.
The facility failed to ensure a signed consent was obtained before starting a new psychotropic medication for one resident, #4. The deficient practice could lead to a resident’s responsible party not being informed of the risk and benefits of a resident's medications.Â
The facility failed to ensure an allegation of abuse for one resident (#4) was reported to the State Agency (SA) within the timeframe established by regulations. The deficient practice could lead to continued abuse of residents.
Based on review of the clinical record, interviews, and review of the facility’s policies and procedures, the facility failed to protect the rights of one resident (#6) to be free from abuse from another resident (#9). The deficient practice could lead to sustaining injuries.
The facility failed to ensure a signed consent was obtained before starting a new psychotropic medication for one resident, #4. The deficient practice could lead to a resident’s responsible party not being informed of the risk and benefits of a resident's medications.Â
Jan 26, 2026Complaint14Report
The onsite complaint survey was conducted on January 26, 2026 through January 28, 2026 and investigated:Complaint 2236460Complaint 2235748Complaint 2236442Complaint 2236362Complaint 2236325SF 00138659SF 00136992SF 00153827SF 00115554SF 00156496SF 00156124SF 00156013SF 00150954SF 00149947SF 00148916SF 00125143SF 00121826The following deficiencies were cited:
Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one resident (#191), which provides instructions to meet the resident’s immediate needs. The deficient practice could result in resident's treatments and needs not appropriately addressed.
Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of one resident (#911) to be free from physical abuse by another resident. The deficient practice could result in further abuse of residents and appropriate action not taken.
Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to maintain documentation that an alleged violation related to the allegation of financial misappropriation of property for one resident (#333) by another resident (#91) was thoroughly investigated.
Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#333) to be free from financial misappropriation/exploitation of resident property by another resident (#111). The deficient practice could result in further financial abuse of residents when appropriate actions are not taken.
 Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to identify elopement risks, and plan for effective supervision for resident one of three sampled residents (#888) related to risk factors for cognitively intact residents, and to ensure that one resident (#511) was supervised during activity sessions, and that activities were conducted safely. The deficient practice could result in avoidable accidents.
Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one resident (#191), which provides instructions to meet the resident’s immediate needs.
Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#911) was not subjected to physical abuse by another resident. Â
Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#333) to be free from financial misappropriation/exploitation of resident property by another resident (#111). Â
Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect one resident (#511) rights in a manner that promotes enhancement of the resident’s quality of life by having her own cell phone to access persons and services outside the facility.
Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to review and revised the care plan for one resident (#191) after each fall incident.Â
Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to identify elopement risks, and plan for effective supervision for resident one of three sampled residents (#888) related to risk factors for cognitively intact residents, and to ensure that one resident (#511) was supervised during activity sessions, and that activities were conducted safely.Â
Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to maintain documentation that an alleged violation related to the allegation of financial misappropriation of property for one resident (#333) by another resident (#111) was thoroughly investigated. The deficient practice could result in further financial abuse of residents when appropriate actions are not taken.
Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to review and revised the care plan for one resident (#191) after each fall incident. The deficient practice could place the resident at risk for more falls.
Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect one resident (#511) rights in a manner that promotes enhancement of the resident’s quality of life by having her own cell phone to access persons and services outside the facility. The deficient practice could lead to residents’ rights being violated.
Jan 5, 2026Complaint
An onsite complaint survey was conducted on January 5, 2026 for the investigation of intakes #2694511, #2694786, and #2693631.The following deficiencies were cited:
Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and policy review, the facility failed to protect the resident’s (#10) rights to be free from abuse by another resident (#5). This deficient practice could result in further incidents of resident to resident abuse. Â
Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and policy review, the facility failed to protect the resident’s (#10) rights to be free from abuse by another resident (#5). Â
Dec 10, 2025Complaint
An onsite complaint survey was conducted on December 10 through 11, 2025 for the investigation of intake #00152654 and 00151196. Following deficiencies were cited:
Based on clinical record review, interviews, review of facility documentation and policies, the facility failed to protect The rights of one resident (# 07) to be free from verbal and physical abuse by another resident (#33).  This deficient practice has the potential to violate the resident’s right to safety and prevent further harm. The sample size was 5. The facility census was 122.   Â
Based on clinical record review, interviews, review of facility documentation and policies, the facility failed to protect The rights of one resident (# 07) to be free from verbal and physical abuse by another resident (#33).  This deficient practice has the potential to violate the resident’s right to safety and prevent further harm. The sample size was 5. The facility census was 122. Â
Nov 13, 2025Complaint
The investigation of Complaints 2650863, 00148770, 00148771, 2653272, 00149035, 2654721, 00149200, 00149199, 2658547, 00149672, and 00149673 was conducted on November 13, 2025. The following deficiencies were cited:
Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to protect the rights of 2 of 8 sampled residents (Resident #2 and #6) to be free from abuse by another resident (Resident # 1 and #5). The deficient practice could result in other residents being abused.
Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to protect the rights of 2 of 8 sampled residents (Resident #2 and #6) to be free from abuse by another resident (Resident # 1 and #5). The deficient practice could result in other residents being abused.
Oct 23, 2025Complaint
The Risk Based survey was conducted October 23, 2025 through October 24, 2025 with the following complaints: AZ00178048/2236254, AZ00178974/2236260, AZ00179020/ 2236261, AZ00182250/2236273, AZ00182313 /2236271, AZ00182583 /An offsite follow up survey was conducted on November 13, 2025. There were no deficiencies cited.
Based on clinical record review, resident and staff interviews, and review of policy, the facility failed to protect the rights of four residents (#25, #23, #49, #51) to be free from abuse by other residents (#20, #33, #45). The deficient practice could result in the facility failing to provide sufficient protection to prevent resident to resident abuse.
Oct 20, 2025Complaint
An onsite complaint licensure survey was conducted on October 20, 2025 through October 22, 2025 for the investigation of intakes #00148179, #00148177, #00148028, #00147608, #00147386, #00146774, #00146655, #00146654, #00146706, #00146590, #00146620, #00146618, #00146592, #00146431, #00146465, #00146218, #00146280, and #00147922. The following deficiencies were cited:
Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#200) was free from physical abuse from other residents (resident #300), and the facility failed to ensure that one resident #400 was free from abuse from staff.  This deficient practice could result in further incidents of resident to resident abuse.
Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure appropriate interventions were implemented in accordance with professional standards. This deficient practice could result in further injury.
Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure appropriate interventions were implemented in accordance with professional standards.
Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#200) was free from physical abuse from other residents (resident #300), and the facility failed to ensure that one resident #400 was free from abuse from staff.  This deficient practice could result in further incidents of resident to resident abuse.
Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#200) was free from physical abuse from other residents (resident #300), and the facility failed to ensure that one resident #400 was free from abuse from staff. This deficient practice could result in further incidents of resident to resident abuse.
Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#200) was free from physical abuse from other residents (resident #300), and the facility failed to ensure that one resident #400 was free from abuse from staff. Â
Ownership & Operations
Who Operates This Facility
Sandstone of Tucson Rehab Centre
for profit
Chain Affiliation
Sandstone Healthcare Group
3 facilities nationwide
Chain avg rating: 2.0/5 · Rank 3 of 3 (Worst) (Best)
Ownership & Management
Owners
Nicho Family Trust
Owner · Organization
Sunny Trust
Owner · Organization
Whitte Trust
Owner · Organization
Berkowitz, David
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Meystel, Yosef
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
189 reviews from families & visitors
Official Website
Visit sandstonehc.com
Medicare data downloads
Original nursing home datasets
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