Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Devon Gables Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow infection control practices during catheter care, dining services, and meal tray delivery. A resident with a condom catheter was observed with the drainage bag dragging on the floor, a CNA handled a straw with bare hands before placing it in a resident’s cup, and uncovered drink cups were transported on a meal cart and carried to multiple residents’ rooms. Staff stated these practices did not meet facility expectations and could transmit germs.
A resident with dementia, chronic pain, and other significant diagnoses had OTC topicals and cough drops left in plain view at the bedside without orders for self-administration or evidence of assessment/care planning for self-administration. Observation found antifungal powder, Hibacleanse, Muscle Rub, and cough drops on the nightstand, and both an LPN and the DON stated these items were medications that should not be kept at bedside without proper authorization and secure storage.
Failure to Protect Resident from Peer-to-Peer Abuse: Two residents were involved in an altercation after one disoriented resident entered another resident’s room and yelling was heard. Staff found bruising and abrasions on the resident who entered the room, and both residents reported that the other had struck first. The incident was investigated as an injury of unknown origin and a significant event, with the facility policy defining physical harm from another resident as abuse.
Two residents with dementia and behavioral disturbances were involved in an unwitnessed altercation, resulting in one sustaining an eye injury and the other a hand fracture. The incident was not observed by staff, and the only resident witness was unable to recall details due to advanced dementia. Facility investigation relied on interviews and post-incident assessments.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with severe cognitive impairment and multiple medical conditions suffered a hip fracture after falling during a hoyer lift transfer when the sling tore. Staff interviews indicated that the sling had visible signs of fraying and concerns about its integrity had been reported prior to the incident, but the sling was not removed from use. The facility's protocol required checking sling integrity before transfers, but this was not effectively implemented, leading to the resident's injury.
A facility failed to protect residents from abuse, resulting in a physical altercation between two residents and inappropriate sexual behavior involving another resident. Despite known behavioral issues, the facility did not prevent these incidents or adequately assess residents' ability to consent, nor did it update care plans to reflect behavioral changes.
A resident with Alzheimer's and a history of falls experienced preventable falls due to inconsistent interventions. Despite being at risk, interventions were canceled without replacements, leading to a fracture. Staff interviews revealed inconsistencies in fall prevention measures, and the DON acknowledged that the removal of interventions did not meet expectations.
Infection Control Failures in Catheter Care, Straw Handling, and Meal Delivery
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control practices were followed for catheter bag placement, dining services, and meal tray delivery for multiple residents. Resident #9 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, vascular dementia, psychotic disturbance, mood disturbance, schizoaffective disorder-bipolar type, hypertension, urinary incontinence, and other conditions. The care plan directed staff not to allow the tubing or drainage system to touch the floor and to keep the bag below the bladder. During an observation in the central hallway, the resident was seen maneuvering his wheelchair while the catheter bag was dragging on the floor underneath the wheelchair. The DON observed the same condition and stated the catheter bag should have a privacy bag and should not touch the floor. Resident #117 was admitted with diagnoses including Huntington's disease, PTSD, unspecified dementia, anxiety disorder, restless and agitation, and fever. The quarterly MDS indicated severe cognitive impairment. During an observation in the main dining room, a CNA retrieved a straw for the resident, removed the paper cover from both ends, touched the straw with bare hands, and then placed it into the resident's cup. A dietary aide stated that a drinking straw should never be touched with bare hands and identified the action as staff #217's. Staff #217 stated that the top of the straw should not be touched with bare hands because it could transmit germs. Meal tray delivery practices were also observed for residents #110, #52, and #145. Resident #110 had diagnoses including senile degeneration of the brain, congestive heart failure, dementia, chronic bronchitis, and other conditions, and had a BIMS score of 15. Resident #52 had diagnoses including a right femur fracture, periprosthetic fracture around the right knee joint, wound vac, displaced patella fracture, and vascular dementia. Resident #145 had diagnoses including spastic diplegic palsy, atrial fibrillation, diarrhea, peripheral vascular disease, and long-term anticoagulant use, with a BIMS score of 15. A meal cart with three trays was observed with uncovered drinks on each tray. The cart remained outside resident #110's room for about 7 minutes before a CNA delivered the tray with an uncovered cup. The cart was then pushed about 46 feet to resident #145's room with uncovered cups, and the remaining tray and uncovered cup were then carried about another 45 feet to resident #52's room. Staff stated that drink cups should be covered when transported and that the uncovered cups had not been covered as expected.
Medications Left at Bedside Without Self-Administration Orders
Penalty
Summary
The facility failed to ensure medications were administered and stored according to policy for one resident who was admitted and readmitted with multiple diagnoses including degenerative disease of the nervous system, dementia, anxiety, chronic pain, obesity, an indwelling urethral catheter, and other psychoactive substance dependence. The resident’s care plan identified risk for skin impairment related to incontinence and clothing/brief use, and risk for altered comfort related to chronic pain. The annual MDS showed a BIMS score of 14, indicating the resident was cognitively intact. The physician orders included Muscle Rub (methyl salicylate-menthol) to be applied every shift, Hibacleanse to the legs with showers twice weekly, and Miconazole Nitrate powder to the abdominal pannus with Interdry; however, there was no evidence of an order for self-administration of these items. There was also no order in the EHR for Halls Cough Drops, and the record contained no evidence of an assessment or care planning for self-administration of medications. During observation, the resident’s night table and bedside table had a Thera Antifungal Powder container, Hibacleanse antiseptic skin cleanser, Muscle Rub, and a bag of cherry flavored Halls Cough Drops in plain view. The resident stated the cough drops had been brought in by his brother and that staff knew about the items. An LPN stated these items were medications and should not be at bedside without an order and self-administration approval, and the DON stated medications should be kept in the treatment or medication carts or in a secured location such as a lock box, locked drawer, or medication cart. The facility policy stated residents may self-administer medications or treatments only if the attending physician, with the interdisciplinary care planning team, determined they could do so safely.
Failure to Protect Resident from Peer-to-Peer Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident when two residents became involved in an altercation inside one resident’s room. One resident had diagnoses including unspecified dementia, altered mental status, and brief psychotic disorder, and had a psychosocial care plan related to adjustment to living in a secure environment because of dementia, memory impairment, and a history of attempts to elope and wandering. Another resident had diagnoses including vascular dementia, unspecified psychosis, anxiety disorders, depression, chronic obstructive pulmonary disease, and hypertension, and had no documented wandering behaviors or resident altercations in the reviewed record before the incident. On the day of the event, staff heard yelling coming from the room and found the resident with dementia inside the other resident’s room. The resident with dementia had entered the room while disoriented and confused, and staff observed that he had bruising and abrasions to the left outer eye, left shin, and right knee. The resident denied pain or discomfort and said he felt safe. A skin assessment documented bruising and abrasions to the left outer eye, bilateral upper extremities, left shin, and right knee, and the event was recorded as wandering behavior with injury. The other resident reported that the resident with dementia hit him, while the resident with dementia stated that the other resident had hit him multiple times on the shoulder and thigh and that he struck back in self-defense after the other resident entered his room and attempted to take his belongings. Staff interviews confirmed that yelling was heard, the residents were separated, and new bruising was observed on the resident who had entered the room. The facility’s investigation identified the event as an injury of unknown origin and a significant event, and the facility policy defined abuse as any act resulting in physical harm, pain, or mental anguish, including physical abuse.
Unwitnessed Resident-to-Resident Altercation Resulting in Injuries
Penalty
Summary
A resident with dementia and behavioral disturbances, who was unable to complete a mental status assessment, was involved in an unwitnessed altercation with another resident diagnosed with dementia and behavioral disturbances but who was cognitively intact. The incident occurred when the first resident entered a room and got into bed, where the second resident and another individual were present. The second resident attempted to remove the first resident from the bed, began yelling, and physically tried to pull the resident out. During the altercation, the first resident sustained a lump and redness to the left eye, while the second resident later exhibited edema and an acute fracture to the right hand. The facility's investigation revealed that the event was not witnessed by staff, and the only resident witness was unable to recall details due to advanced dementia. Interviews with both involved residents indicated that the second resident admitted to putting hands on the first resident but did not recall the specifics, while the first resident reported being struck in the eye. The facility's policy requires prompt reporting and thorough investigation of abuse or suspected abuse, including resident-to-resident altercations, but the incident was not observed by staff and relied on post-incident interviews and assessments.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Resident Fall and Injury Due to Use of Damaged Hoyer Sling During Transfer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical diagnoses, including epilepsy and a right femur fixation device, was not kept free from accident hazards during a hoyer lift transfer. The resident required a three-person assist for all transfers due to his use of a geriatric chair, as documented in his care plan. During a transfer from his geri chair back to bed, the hoyer sling tore, causing the resident to fall to the floor and sustain a right hip fracture. Staff interviews revealed that the facility's protocol required checking the integrity of the hoyer sling before use and ensuring the correct size and type of sling was used for each resident. Multiple CNAs described their process for inspecting slings, including checking for fraying, tears, and weakened seams. One CNA reported noticing fraying and unusual noises from the sling during a previous transfer and stated that these concerns were reported to a team lead. However, the sling was not removed from service and was used again, resulting in the incident. The Director of Nursing confirmed that the expectation was for staff to thoroughly check the integrity of the sling and to remove any with signs of wear or damage. The investigation determined that the root cause of the incident was the use of a hoyer sling with impaired integrity, which had been identified by staff prior to the accident but not acted upon. The clinical record did not show any orders or assessments related to the accident at the time of the incident.
Failure to Prevent Resident Abuse and Inadequate Care Planning
Penalty
Summary
The facility failed to protect three residents from abuse, resulting in incidents involving physical altercations and inappropriate sexual behavior. Resident #24, who has Alzheimer's disease and vascular dementia, and Resident #33, diagnosed with schizoaffective disorder and unspecified dementia, were involved in a physical altercation. The incident occurred when Resident #33 mistakenly entered Resident #24's room through a shared bathroom, leading to a verbal and physical confrontation. Staff interviews revealed that Resident #24 had been exhibiting increased behavioral episodes, and Resident #33 was known to be territorial about his space. Despite these known behaviors, the facility did not effectively prevent the altercation. In another incident, Resident #24 was involved in inappropriate sexual behavior with Resident #11, who also has advanced dementia. Staff observed Resident #24 stroking Resident #11's penis while Resident #11 was in Resident #24's bed. Both residents were on a locked dementia unit, and staff immediately separated them and implemented increased supervision. However, the facility failed to have a care plan in place for Resident #11's known disinhibited behaviors, despite previous instances of public masturbation being documented in progress notes. Interviews with staff and the Director of Nursing indicated that neither Resident #24 nor Resident #11 was capable of consent due to their cognitive impairments. The facility's policy on preventing abuse emphasizes the protection of residents from abuse by anyone, including other residents. However, the facility did not adequately assess the residents' ability to consent to sexual interactions, nor did it update care plans to reflect changes in residents' behaviors, contributing to the incidents of abuse.
Failure to Prevent Falls for a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from preventable falls, which could result in increased morbidity and mortality. The resident, who was admitted with Alzheimer's disease, mood disorder, and vascular dementia, had a history of falls and was identified as being at risk for falls. Despite this, the facility did not maintain consistent interventions to prevent falls. On July 27, 2023, the resident was found on the floor in their room, and although a care plan intervention was added to remind the resident not to ambulate without assistance, it was canceled the same day without replacement. Subsequently, on August 5, 2023, the resident fell again in the dining room, resulting in a fracture of the left superior and inferior pubic rami. Interviews with staff revealed inconsistencies in the implementation and maintenance of fall prevention interventions. A CNA mentioned that the resident had a pad beside their bed, while an LPN described interventions such as positioning the bed to the lowest setting and using a fall mat. However, the Director of Nursing acknowledged that interventions were removed without replacements, which did not meet the facility's expectations. The facility's policy on care plans emphasized the need for ongoing assessments and revisions as residents' conditions change, but this was not adhered to in the case of the resident, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tucson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sandstone Estates Rehab Centre | 0.2 mi | ★★★★★ | 9 | 0 |
| Sabino Canyon Rehabilitation & Care Center | 0.8 mi | ★★★★★ | 6 | 0 |
| Pueblo Springs Rehabilitation Center | 0.9 mi | ★★★★★ | 1 | 0 |
| Foothills Rehabilitation Center | 1.2 mi | ★★★★★ | 26 | 0 |
| Handmaker Home For The Aging | 1.2 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.