Foothills Rehabilitation Center: Care Plan Failures - AZ
Inspectors documented the gap during a complaint inspection on March 28, 2026. The resident, identified in inspection records as Resident #167, had been assessed as requiring total dependence and a two-person assist for bathing as far back as June 2, 2023. A second assessment on September 2, 2023 said the same thing. His care plan did not reflect that requirement until December 11, 2023, more than six months after the first assessment established it.
The Director of Nursing confirmed all of it.
She reviewed both assessments during the inspection and acknowledged that the care plan should have matched what the assessments showed. It did not. She told inspectors directly: if a resident's required supports are not identified on the care plan, there is a risk of injury to the resident.
The facility uses a standard process in which a nurse conducts assessments, those findings feed into the Minimum Data Set, and the care plan is then built from the MDS. The Director of Nursing described that process herself. The June 2023 MDS showed total dependence and a two-person assist requirement. The September 2023 MDS showed the same. Neither finding made it into the care plan.
A certified nursing assistant who worked with Resident #167 told inspectors she provided his care based on the care plan. She said she did not know why the care plan failed to reflect that he needed two people for bathing.
That answer captures the problem precisely. Staff work from care plans. If the care plan is wrong, the care follows it anyway.
A two-person assist requirement is not a minor notation. It exists because moving or bathing a fully dependent resident alone creates real physical risk, to the resident and to the staff member. A resident who cannot support his own weight, cannot reposition himself, cannot grip a rail or signal distress in time, depends entirely on whoever is in the room to know what he needs and to have brought help. If the care plan does not say two people are required, one person may show up.
Whether that happened here, the inspection report does not say. What it does say is that for more than six months, the documentation that would have prevented it was absent.
The facility's own policy, last reviewed in October 2025, requires that a comprehensive care plan be developed within seven days of completing an MDS assessment and that it reflect the resident's current assessed needs. The June 2023 MDS was completed. The care plan was not updated to match it. The September 2023 MDS was completed. The care plan was still not updated. By the time the December 2023 correction was made, two assessment cycles had passed without the care plan catching up.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, affecting a small number of residents.
The nursing assistant's answer stays with you, though. She gave Resident #167 his care. She based it on what the care plan said. She did not know what the care plan was missing.
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 violations during a health inspection on March 28, 2026.
Inspectors documented the gap during a complaint inspection on March 28, 2026.
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.