Foothills Rehabilitation Center: Fall After Staff Neglect - AZ
The March 28 complaint inspection at Foothills, located at 2250 North Craycroft Road, turned on a single, documented fact: Resident #167 had been assessed through the Minimum Data Set process as requiring a two-person assist for bathing. He moves a lot, a licensed practical nurse explained to inspectors. That is precisely why two people were required. On the day in question, one aide showed up. He fell.
The administrator, interviewed during the inspection, did not dispute the basics. She confirmed that Resident #167's MDS assessment called for two-person assistance. She said the situation did not meet her expectations. She acknowledged that failing to provide the supports identified in a resident's assessment can cause harm.
That acknowledgment, measured and administrative in its phrasing, understated what her own staff said more plainly.
A certified nursing assistant, identified in inspection records as Staff #156, was interviewed at 11:04 in the morning on March 28. She said neglect happens when staff fail to meet residents' needs. When inspectors asked her directly whether sending one aide to bathe a resident whose assessment required two, and that resident then falling, would constitute neglect, she said yes. The resident did not receive the required level of assistance. That was her answer.
Nine minutes later, at 11:13, inspectors sat down with a licensed practical nurse identified as Staff #120. She gave the same answer, in more detail. Neglect, she said, is when pain medications are given without a proper assessment, or when cares are simply not provided. She said that if a resident is a two-person assist, there must be two people. She explained why Resident #167 specifically required that level of help: he moves a lot. One person is not enough to keep a resident who moves unpredictably safe during a bath.
Then she described what neglect costs. Injury. Skin damage. Emotional harm. Residents losing their trust in the staff who are supposed to keep them safe.
That last part is not a regulatory category. It does not appear in the deficiency tag or the plan of correction language. It is what a nurse said, in her own words, about what happens to a person when the people responsible for their safety fail them.
Foothills is a rehabilitation center, which means a significant portion of its residents are there precisely because their bodies are unreliable, because they have recently had surgeries or strokes or falls, because they need help with the basic physical tasks that most people perform without thinking. A bath is not a minor event for a resident like Resident #167. It requires planning, coordination, and the right number of hands. His assessment said two. One showed up.
The facility's own accident and incident policy, last revised in November 2023, requires that all accidents or incidents on the premises be investigated and reported to the Director of Nursing and the Administrator. The inspection record does not describe the outcome of any such investigation, or whether one was completed before inspectors arrived.
The fall risk assessment policy in place at Foothills calls for nursing staff to work with the attending provider, consultant pharmacist, therapy staff, and others to identify and document each resident's risk factors for falls. Resident #167's risk factors had been identified. They had been documented. The MDS assessment existed. The two-person requirement was written down. None of that prevented what happened, because documentation is not the same as compliance.
This is the gap that the inspection exposed. Not a missing policy. Not an unassessed resident. The assessment was done. The risk was known. The requirement was clear. A staff member showed up alone anyway, and a resident who moves a lot was left to be bathed by a single pair of hands, and he fell.
The administrator's phrase, that this did not meet her expectations, is worth sitting with. It suggests that the expectation existed, that the standard was understood, that the failure was not a matter of confusion about what was required. Someone knew what Resident #167 needed. Someone sent one person instead of two.
The inspection was conducted in response to a complaint. The records do not identify who filed it, or what specifically prompted it. Complaint inspections are triggered when someone, a resident, a family member, a staff member, an outside observer, contacts regulators with a concern serious enough to send inspectors to the door. In this case, inspectors arrived and found what the complaint apparently described.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's attempt to calibrate severity across thousands of facilities and millions of residents. It does not mean the fall was minor. It means inspectors found evidence of a violation that, in their assessment, resulted in minimal harm or created the potential for actual harm. A resident fell. Whether his injuries were serious enough to push the finding into a higher harm category is not stated in the inspection narrative.
What is stated is that two of the facility's own clinical staff, a CNA and an LPN, confirmed to inspectors that what Resident #167 experienced was neglect. Not a mistake. Not a miscommunication. Neglect.
The LPN's words at the end of her interview describe something that does not resolve cleanly into a deficiency tag or a corrective action plan. Residents can lose their trust in staff to keep them safe. That is not a temporary condition that a revised policy fixes. A resident who has fallen because the people responsible for his care sent one aide instead of two does not simply resume trusting that the right number of people will show up next time. The trust has to be rebuilt, if it can be rebuilt at all.
Resident #167 was assessed as needing two people because he moves a lot. He fell. His nurses said it was neglect. His administrator said it did not meet her expectations. And somewhere in the facility at 2250 North Craycroft Road, he is still a resident who moves a lot, still dependent on staff to show up in the right numbers, still waiting to find out whether the next bath will go differently.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Foothills Rehabilitation Center from 2026-03-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
FOOTHILLS REHABILITATION CENTER in TUCSON, AZ was cited for neglect violations during a health inspection on March 28, 2026.
He moves a lot, a licensed practical nurse explained to inspectors.
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.