Foothills Rehabilitation Center: Resident Attack Failures - AZ
The resident who struck the blow, identified in inspection records as Resident #85, had been a known risk since at least May 2021. His care plan that year noted he yelled profanities, argued with himself, and hit his own hands together in a threatening manner even when he was alone in a room. The interventions: more counseling sessions, distraction with things he liked.
It didn't hold.
By June 2022, the facility had escalated to requiring two staff members for every interaction with him, a level of supervision called 2:1 care, after a pattern of false accusations and safety concerns. By October 2022, his care plan had grown longer, more detailed, and more alarmed. Staff were told to seat other residents away from him, reduce noise and crowding around him, pull him from group activities when his behavior became unacceptable, and move him to a quiet environment whenever he turned verbally abusive. The plan used the phrase "physically aggressive residents" as one of the stimuli to keep away from him — which raised a question the inspection record doesn't answer: how a man flagged as a physical threat ended up close enough to another resident to hit him.
In February 2023, nursing notes recorded two straight days of deterioration. On February 2 and 3, Resident #85 was spitting on towels and trash cans, making negative statements toward staff, repeatedly yelling and cursing, throwing items throughout his shifts, and showing exit-seeking behavior. Staff tried redirection. They tried distraction. They offered food and fluids. They modified the environment. According to the documentation, none of it produced any change in his behavior.
The nursing note from February 3 added that Resident #85 was propelling his wheelchair around the unit, talking loudly to people who were not there.
At some point during this period, he struck Resident #144 with a closed fist.
A certified nursing assistant, identified in the report as Staff #171, was present when it happened. She saw it. She separated the two residents immediately. Resident #144 was left with slight redness to his left upper chest.
The inspection, completed March 28, 2026, classified the incident as causing actual harm.
What the records show, across nearly five years of documentation, is a facility that knew this resident's behavior could escalate to physical violence, wrote that knowledge into care plan after care plan, and watched its own interventions fail repeatedly without arriving at anything that worked. The 2:1 supervision requirement from June 2022 was meant to ensure a resident with his history was never left in a position to harm someone else. The inspection record does not explain how he reached Resident #144.
Resident #144 struck back, the records note. A closed fist. The redness on his chest was the documented injury. Whether either resident received follow-up beyond the immediate separation, the inspection report does not say.
What it does say is that Foothills Rehabilitation Center had, in writing, a portrait of a man whose behavior had been escalating for years, whose environment required careful management, and whose proximity to other residents was supposed to be controlled. The staff member who witnessed the assault responded correctly in the moment. The question the inspection raises is what happened in all the moments before it.
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.
The resident who struck the blow, identified in inspection records as Resident #85, had been a known risk since at least May 2021.
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.