Foothills Rehabilitation Center
FOOTHILLS REHABILITATION CENTER in TUCSON, AZ — inspection on March 28, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
ability to come out of their room into communal areas.
She stated that she did not like the appearance
200-hall.
Staff #50 was directed to the hole in the wall by the nurse's station and stated that she was
the bottom edge, with the hole measuring approximately 2 x 4 inches.
She stated that the risk to residents could include residents attempting to put their hand in the hole and potentially cutting themselves on the jagged edges of the plate cover.An interview was conducted on March 26, 2026 at 10:24 AM with staff #48, Maintenance Director.
Staff #48 stated that the facility generally receives 20 plus work orders daily and the department would prioritize anything with potential resident safety concerns and that there are completed right away.
Staff #48 stated that they are in the process of renovating some of the rooms and that some had already been entirely renovated.
Staff #48 further stated that he had started renovations approximately 6 months ago on the 200-hall, but that they still had a lot left. He stated that outstanding work orders for the 200 hall included repairs to the main door and hallway painting. He stated that in the 200-hall dining area, just some painting and improvements were needed.
When asked about the baseboards, he stated that he was aware and that they would be fixed.
When asked about the hole in the wall, staff #48 stated that he was aware that there was a partial plate cover over a hole by the nurse's station on the 200-hall which needed to be replaced.
Staff #48 stated that that this issue would qualify as a high priority issue because of the broken plate and because it was a 'lock-down' unit.
Staff #48 stated that the issue was reported verbally to him on March 15, 2026. He stated that it should have been fixed by now and that the risk included someone getting cut.
When asked he further stated that the 200-hall, currently, does not constitute a home-like environment and stated that additional risks to residents could include resident's feeling bad about their current living situation.An interview was conducted on March 26, 2026 at 11:58 AM with staff #116, Administrator.
Staff #116 stated that a homelike environment includes a resident feeling comfortable in their room/ facility and can include having their belongings, hygiene supplies being afforded privacy and even having one plant if they are not on the respiratory unit. If a resident voices concern regarding home-like environment then they are placed on high-priority to ensure that they do feel comfortable in their setting.
Staff #116 stated that holes in walls are fixed the minute maintenance finds out about them, but stated that maintenance does need to be made aware of them by staff or residents.
Staff #116 stated that one of the challenges that had been encountered was staff not providing written work orders to the maintenance department.
The administrator further stated that a hole in the wall with a partial plate cover and jagged edges could potentially cause a skin tear for a resident and that no one likes to see holes in the wall.A review of the facility policy titled Quality of Life-Homelike Environment with a revised date of February 2014 revealed that it's focus was to provide the residents with a safe, clean, comfortable homelike environment.
035064 03/28/2026
Foothills Rehabilitation Center 2250 North Craycroft Road Tucson, AZ 85712
According to the
immediately separated Resident #144 and the other resident (#85).
The documentation included that
-Resident #85 was admitted on [DATE] with diagnoses of Schizoaffective disorder, personality disorder, anxiety and major depressive disorder.
The care plan dated May 28, 2021 included resident exhibited behaviors such as yelling out profanities, argued with self, hit hand into other hand in a threatening manner even when he was alone in the room.
Interventions included increasing sessions with counselor and distracting the resident with things he likes.
The care plan dated June 28, 2022 included that resident was on 2:1 for cares related to false accusations and safety.
Interventions included 2:1 for all cares, redirection as needed and offering phone and outdoor time.
The care plan revised on October 10, 2022 included resident exhibited verbally inappropriate behavioral symptoms towards peers.
Interventions included to allow distance in seating other residents around resident #85, to avoid over-stimulation/reducing external stimuli (e.g., noise, crowding, other physically aggressive residents), to provide 1:1 sessions with resident with every disruptive blow up, to remove resident from group activities when behavior is unacceptable, to redirect /divert resident's behavior by engaging with topics that interest him, to redirect from others when behaviors increase, and, when resident becomes verbally abusive or disruptive, move resident to a quiet, calm environment.
The behavior notes dated February 2 and 3, 2023 included that the resident was spitting on towels and trash cans, making negative statements toward staff, exhibiting exit-seeking behavior, and repeatedly yelling, cursing, and throwing items throughout the shift.
According to the documentation, staff attempted redirection and education, which were only briefly effective.
Additional interventions—including distraction, offering food and fluids, and modifying the environment—were implemented; however, these measures did not result in change in the resident's behavior.
The nursing note dated February 3, 2023 revealed Resident #85 continued to propel his wheelchair around the unit talking to people who were not there, had loud
035064 03/28/2026
Foothills Rehabilitation Center 2250 North Craycroft Road Tucson, AZ 85712
profanities, argued with self, hit hand into other hand in a threatening manner even when he was alone
accusations and safety.
Interventions included 2:1 for all cares, redirection as needed and offering phone and outdoor time.
The behavior note dated February 3, 2023 included resident had exhibited behaviors all morning, yelling and cursing at staff, talking to people who were not present, hitting self in head, throwing cups/water, and throwing medications in trash can.
Per the documentation, multiple attempts were made to redirect, offer of food, fluids, snack, and was given choices on how he would like his medications as well as and attempted to provide a change in environment.
However, all attempts were unsuccessful; and, the PRN (as needed) medications for anxiety was administered with minimal effect noted.
The nursing note dated February 3, 2023 revealed Resident #85 continued to propel his wheelchair around the unit talking to people who were not there, had loud outbursts, periodic yelling at staff, was cursing, and hitting self in head.
The documentation also included that the resident had active delusions and hallucinations stating that he lost 319 pounds in the past 6 months and maybe he can eat a piece of white bread to keep from dying.
Per the documentation, the resident received his PRN medication but with minimal effect; and, staff continued to provide NPI (non-pharmacological interventions) to assist with de-escalation of his behaviors.
A nursing note dated February 6, 2023 at 5:30 a.m., Resident #85 was sitting in his wheelchair looking out the window on the double door when another resident (#144) in a wheelchair approached Resident #85 from behind.
The documentation included that Resident #85 then turned his upper body and struck the other resident (#144 on the left upper chest with his forearm According to the documentation, the other resident (#144) then struck Resident #85 with a closed fist in the center of his back.
According to the documentation, a certified nurse assistant (CNA/staff #171) was present, saw the incident and immediately separated Resident #85 and the other resident (#144); and that, Resident #85 did not have any injuries noted.
The initial self-report dated February 6, 2023 included that Resident #85 had an altercation with Resident #144.
Per the documentation, Resident #85 was at the doorway and Resident #144 came to the doorway too; and that, Resident #85 turned around and hit Resident #144.
The undated facility
035064 03/28/2026
Foothills Rehabilitation Center 2250 North Craycroft Road Tucson, AZ 85712
Interview other residents to whom the accused employee provides care or services.
035064 03/28/2026
Foothills Rehabilitation Center 2250 North Craycroft Road Tucson, AZ 85712
documentation that the resident or representative was provided with a copy of baseline care plan.
nursing, mental and psychological needs is developed for each resident.
The resident is informed of
conferences. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record.
The explanation should include what steps were taken to include the resident or representative in the process.
035064 03/28/2026
Foothills Rehabilitation Center 2250 North Craycroft Road Tucson, AZ 85712
for bathing.
She further shared that she did not know why the care plan did not reflect that the
assessed, the MDS is reviewed and then the care plan is developed from the information obtained in
development and/or updates.
Staff #7 reviewed the June 2, 2023 MDS for Resident #167 and shared that he was total dependence and a 2-person assist for bathing.
She also reviewed the September 2, 2023 MDS for Resident #167 and shared that he was total dependence and required 2-person assist for bathing at that time as well.
When reviewing the care plan for Resident #167, she shared that it identified that Resident #167 was a 2-person assist with showers starting December 11, 2023.
She further shared that there was no information, regarding bathing with 2-person assist, in the care plan prior to December 11, 2023.
Staff #7 explained that the care plan should have reflected that the resident was a 2-person assist prior to that date and confirmed that the care plan did not match the information in Resident #167's MDS.
Staff #7 explained that if a resident's required supports was not identified on the care plan, there would be a risk of injury to the resident.
Review of the facility's policy and procedure titled ?Care Plans - Comprehensive' (last reviewed October 2025) indicated the comprehensive care plan is to be developed to address each resident's medical, nursing, mental, and psychosocial needs.
The policy further specified the care plan is to be based on a thorough assessment, including the MDS, and must be developed within seven days of completion of the MDS to reflect the resident's current assessed needs.
035064 03/28/2026
Foothills Rehabilitation Center 2250 North Craycroft Road Tucson, AZ 85712
said that based on the MDS assessment, Resident #167 was supposed to have two people helping
interview with CNA (Staff #156) was conducted on March 28, 2026 at 11:04 A.M.
Staff #156 revealed
and neglect training during monthly in-services and annual in-depth sessions.
When asked whether providing a 1-person assist to a resident assessed as requiring a 2-person assist for bathing, resulting in a fall, would constitute neglect, she confirmed that it would, as the resident did not receive the required level of assistance. An interview was conducted on March 28, 2026 at 11:13 A.M. with Licensed Practical Nurse (LPN/Staff #120) who stated that neglect occurs when pain medications were given without a proper pain assessment or when cares were not being provided to the resident.
She said providing a 1-person assist to a resident assessed to require a 2-person assist for bathing and resulting in a fall, would constitute neglect.
She said that the resident is a 2-person assist because the resident moves a lot; and, if a resident was a 2-person assist, then there must be 2 people helping the resident.
The LPN further stated that neglecting the residents could result in injury, skin damage, residents could be emotionally affected and they could lose their trust in staff to keep them safe.A review of the facility's policy and procedure titled Accidents and Incidents - Investigating and Reporting indicated it was last revised in November 2023.
The policy and procedure indicated that all accidents or incidents that take place on the premises will be investigated and reported to the Director of Nursing and Administrator.The facility policy on Fall Risk Assessment included that the nursing staff, in conjunction with the Attending Provider, Consultant Pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls.
035064 03/28/2026
Foothills Rehabilitation Center 2250 North Craycroft Road Tucson, AZ 85712
During an interview with the with the Director of Nursing ( DON/Staff #7) conducted on March 27, 2026 at 11:54 AM, the DON stated that the resident's status related to EBP and/or TBP (transmission-based precautions) was communicated with a banner on the facesheet of clinical records; and, there would be signs about this posted on the resident's room door.
She stated that it does not meet her expectation if there were no signs outside the resident's door and the resident was on EBP.
The DON further stated that an EBP sign explains to staff/visitor when to wear PPE (Personal Protective Equipment) which was a barrier of infection between patients and employees; and, when PPE was not worn when needed it imposes a risk of infections.
The facility's policy titled Isolation- categories of transmission-based precautions revised April 2012 revealed examples of infections requiring Contact Precautions include, but are not limited to: Infections with multi-drug resistant organisms, Heavily draining wounds with non-contained drainage.
Signs used to alert staff of contact precautions.
The policy further noted that the facility will implement a system to alert staff to the type of precautions the resident requires. It was documented that this facility utilizes the following system for identification of Contact Precautions for staff and visitors: Sign posted on resident room/door See Nurse Before Entering Room.
The facility will also ensure that the resident's care plan and care specialist communication system indicates the type of precautions implemented for the resident.