Foothills Rehabilitation Center: Resident Safety Failures - AZ
The resident, identified in inspection records as Resident #85, turned and struck the other resident, Resident #144, in the left upper chest with his forearm. Resident #144 struck back, hitting Resident #85 in the center of the back with a closed fist. A certified nursing assistant who was present separated them. Resident #85 had no injuries noted. The inspection report does not record whether Resident #144 did.
The incident at Foothills Rehabilitation Center, at 2250 North Craycroft Road, came at the end of three days of documented behavioral crisis that staff had been unable to contain.
Three days earlier, on the morning of February 3, a behavior note described Resident #85 yelling and cursing at staff, talking to people who were not present, hitting himself in the head, and throwing cups of water. Staff tried redirecting him, offered food, offered fluids, offered choices about how he wanted to take his medications, and attempted a change of environment. None of it worked. An as-needed medication for anxiety was administered. It had minimal effect.
By that same afternoon, a nursing note recorded that Resident #85 was propelling his wheelchair around the unit, having loud outbursts, yelling at staff, and hitting himself in the head. He was also experiencing active delusions and hallucinations. He told staff he had lost 319 pounds in the past six months and that he needed to eat a piece of white bread to keep from dying. Staff gave him his as-needed medication again. Minimal effect again. Staff continued what the notes called non-pharmacological interventions to try to bring him down.
His care plan, dated June 28, 2022, had already established that Resident #85 required two staff members for all personal care, a level of supervision tied to false accusations and safety concerns. Interventions listed included redirection, phone access, and outdoor time. The plan was in place. The behaviors documented over those three days in February 2023 suggest it was not enough.
The inspection at Foothills was conducted on March 28, 2026, and classified as a complaint investigation. Inspectors found that the facility had failed to protect residents from the actions of other residents and that the level of harm was characterized as minimal harm or potential for actual harm.
That framing sits uneasily against what the records describe. A man in the grip of active hallucinations, alone at a doorway before dawn, whose emergency medications had already failed twice, was in a position to encounter another resident without adequate supervision in place. The care plan required two staff for his personal care. The notes do not explain who was monitoring his movements at 5:30 a.m., or why.
The facility's own self-report, filed the day of the altercation, described the incident briefly: Resident #85 was at the doorway, Resident #144 came to the doorway, and Resident #85 turned and hit him. The self-report was undated in the inspection documentation.
What the inspection record does not contain is any account of what happened to Resident #144 after the punch landed, whether he was examined, whether he was injured, or whether his family was notified. His presence in the narrative ends at the moment of impact.
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, identified in inspection records as Resident #85, turned and struck the other resident, Resident #144, in the left upper chest with his forearm.
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.