Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Foothills Rehabilitation Center during CMS and state inspections, most recent first.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found multiple food storage and labeling deficiencies in the kitchen and dry storage areas, including open deli meat, frozen vegetables, and chicken stored without labels or open dates, and spoiled mushrooms left in the refrigerator. In dry storage, dented cans of beans, pumpkin, and peaches were stored on regular use racks instead of being segregated as damaged goods. The Dietary Manager acknowledged that all stored food items were expected to be labeled and dated, that produce should be rotated on a first‑in, first‑out basis, and that dented or bulging cans should be kept on a damaged goods shelf, consistent with facility policies on food labeling, dating, and storage.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
A cognitively intact resident with COPD and acute kidney failure had conflicting documentation regarding code status, with the care plan and NP progress notes listing Full Code, a physician order and Daily Report Sheet listing DNR, and a red DNR warning in the EHR, while the resident stated he wanted life-saving measures and did not want to be DNR. Review of the code book at the nurses’ station showed no advance directive or DNR sheet for the resident, and staff interviews revealed inconsistent knowledge of how to verify code status, with one CNA stating she would perform CPR on all residents regardless of status and another relying on the nurse for this information. The DON acknowledged that the documentation did not match and that the resident, who could make his own decisions, was at risk of not having his wishes followed, despite a facility policy requiring prominent display and care plan integration of advance directives and routine review by the IDT.
A resident with multiple chronic conditions, including morbid obesity, type 2 DM with complications, and chronic respiratory failure, was inaccurately documented as white in the MDS and clinical record, despite a signed Prehospital Medical Care Directive and the resident’s own statement identifying her as black/African American. The MDS coordinator reported that demographic data, including race, are pulled from admissions documentation and acknowledged that the resident’s race should have been coded as black/African American. The DON also confirmed that the clinical record’s identification of the resident as white was inaccurate, contrary to facility policy and RAI guidance requiring accurate, standardized self-reported race data for assessments.
A resident with multiple chronic conditions and an active order for topical miconazole antifungal powder was found with two bottles of the medication on the bedside night table, one empty and one half-full, without any documented assessment, order, or care plan for self-administration. During observations and interviews, an RN, a CNA, and the DON all confirmed that powders are medications and that residents are not permitted to keep medications at bedside without a self-administration order and documented evaluation. Review of the EHR and facility policy showed that required assessments, documentation, and care planning for self-administration had not been completed, even though the medication was accessible in the resident’s room.
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, resulting in a deficiency related to resident safety.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident reported verbal and attempted physical abuse by a nurse. The facility's investigation included interviews with three residents but did not document any staff interviews, despite facility policy requiring such documentation. The DON was not present during the incident, and the Administrator confirmed that staff interviews were not written down.
A resident with a recent colectomy and ileostomy did not have a physician order for colostomy care documented in the clinical record, care plan, or MAR. Staff confirmed the presence of a colostomy bag and described routine care practices, but were unable to locate any formal order for colostomy care. Documentation also showed inconsistent recording of bowel and bladder checks, contrary to facility policy requiring proper treatment orders.
A resident with multiple health conditions was left soiled and unattended by a CNA for approximately 30 minutes, leading to a deficiency in care. The incident was observed by another staff member and the resident's former roommate. Interviews with staff revealed that the facility's policy requires prompt changing of soiled residents to prevent skin breakdown. The Director of Nursing and the Administrator confirmed that the wait time did not meet their expectations for resident care.
A resident with multiple health conditions fell during a Hoyer lift transfer due to a CNA conducting the transfer alone, against facility policy requiring a two-person assist. The resident sustained injuries, including a fractured ankle and lumbar compression fractures, after the CNA left them unattended to replace the lift's batteries and then attempted the transfer alone.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Improper Food Labeling and Storage Practices in Kitchen and Dry Storage
Penalty
Summary
Surveyors identified a deficiency in food storage and labeling practices in the facility’s kitchen and storage areas. During an observation of the kitchen refrigerator with the Dietary Manager, an open 2‑pound package of deli smoked ham was found inside a Ziploc bag with no open date on either the original packaging or the bag. A box of mushrooms labeled with a production date was also found in the refrigerator; the mushrooms were dark brown and mushy. The Dietary Manager acknowledged that the mushrooms were browning and should be going in the trash. In the kitchen freezer, surveyors observed an open 64‑ounce bag of frozen mixed vegetables with no open or use‑by date, as well as an open, unlabeled, and undated bag of cream‑colored, meat‑like textured pieces that the Dietary Manager identified as boneless skinless chicken pieces. The Dietary Manager stated that an open date and label should always be documented once the original package has been opened and that without a date, staff would not know when the food item was opened or if it was still good to use. In the dry storage area, surveyors found multiple dented cans, including cans of pinto beans, canned pumpkin, and diced peaches, stored on the regular ready‑for‑use racks rather than in a designated dented section. The dents were located on the seams and body of the cans. The Dietary Manager stated that these cans should not have been stored with usable canned items because of the potential risk of food‑borne illness and that staff were expected to recognize dented cans upon delivery and keep them off the regular racks. In a subsequent interview, the Dietary Manager explained that the expectation was for all food items to be labeled and dated when stored, that produce should be used on a first‑in, first‑out basis, and that she checks produce rotation twice a week while dietary staff are also expected to check but sometimes delay and forget. Facility policies on Proper Labeling/Dating Procedures and Food Storage required that all items in freezers, refrigerators, and dry storage have open dates, that loose items be in containers with open dates, and that dented or bulging cans be placed on a damaged goods shelf and returned for credit. These observations showed that staff did not consistently follow the facility’s own food labeling and storage policies.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
Failure to Accurately Document and Implement Resident Code Status and Advance Directive
Penalty
Summary
The deficiency involves the facility’s failure to accurately document and implement a resident’s advance directive and code status in accordance with the resident’s expressed wishes. The resident, who had COPD, morbidity, and acute kidney failure and was cognitively intact with a BIMS score of 13, had a care plan last reviewed on a specified date that identified him as Full Code, with instructions for staff to perform resuscitation measures per facility guidelines in the event of cardiac or respiratory arrest. However, a physician’s order dated on another specified date indicated the resident’s code status as DNR, and his electronic profile displayed a red DNR warning next to his picture. The resident’s code status was therefore inconsistently documented within the clinical record. Progress notes further contributed to the inconsistency, with two separate entries on the same morning, each e-signed by different nurse practitioners, both documenting the resident as Full Code. At the nurses’ station, review of the residents’ code book revealed there was no advance directive or DNR sheet for this resident, despite other documentation indicating DNR status. An undated Daily Report Sheet provided by an LPN listed the resident’s code status as DNR, and the LPN stated she believed the resident was still DNR, noting he had been on hospice until several weeks prior and had been considering changing his code status to Full Code, but she did not know if the change had occurred. The DON, when asked, initially stated the resident was DNR, then, upon reviewing the EHR and NP progress note, acknowledged that the documentation was not accurate and did not match. Interviews with staff and the resident highlighted additional issues related to communication and understanding of code status. The resident clearly stated that he wanted life-saving measures and did not want to be DNR. A CNA reported that she did not memorize residents’ code status and would ask the nurse, while another CNA stated she would provide CPR to all residents regardless of code status and did not know how to find out a resident’s code status. The DON confirmed that CNAs are certified in CPR and that residents can change their code status at any time, and that code status should be updated immediately when a resident changes their mind. The facility’s advance directives policy required that code status be displayed prominently in the medical record/EHR, reflected in the care plan, and routinely reviewed by the interdisciplinary team with the resident, but in this case, the resident’s expressed preference for Full Code was not consistently or accurately documented across the care plan, physician orders, progress notes, and code status reference materials.
Inaccurate MDS and Clinical Record Demographics for Resident Race
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate assessment for one resident by incorrectly documenting the resident’s race in the clinical record and MDS. The resident was admitted with multiple diagnoses including presence of a cardiac pacemaker, morbid obesity, type 2 diabetes mellitus with skin complications and diabetic polyneuropathy, and chronic respiratory failure with hypoxia. The admission MDS assessment documented the resident as white in Section A101, and the electronic medical record face sheet also identified the resident as a white female. However, a Prehospital Medical Care Directive signed by the resident documented the resident’s race as black, and during an interview the resident self-identified as a black/African American female. Despite this discrepancy, a continuity of care document created later continued to list the resident’s race as white. The MDS coordinator explained that the IDT assesses residents on admission and that MDS staff pull demographic information, including race, from documentation entered by the admissions nurse, and acknowledged that the resident’s race should have been coded as black/African American. The DON also confirmed that the clinical record identified the resident as white and stated this was inaccurate because the resident was black/African American. Facility policy required all persons completing any portion of the MDS to attest to the accuracy of the information, and the RAI manual emphasized that accurate MDS coding and standardized self-reported race data are essential for optimizing resident care and outcomes, yet the resident’s race remained inaccurately documented in the assessment and record.
Medication Left at Bedside Without Self-Administration Assessment or Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were not left at the bedside without an order, assessment, or care plan for self-administration. A cognitively intact resident with multiple medical diagnoses, including disorganized schizophrenia, osteoporosis, chronic bronchitis, neuropathy, and depression, had an active physician order for miconazole nitrate 2% antifungal powder to be applied to the groin and breast folds. The order was initially open-ended and later given an end date, but there was no documentation in the clinical record that the resident had been assessed and determined safe to self-administer medications, nor was there an order or care plan for self-administration. During an observation in the resident’s room, surveyors noted two 3‑ounce bottles of Thera antifungal powder on the night table, one empty and one half-empty. Nursing staff, including an RN, a CNA, and the DON, all acknowledged that powders are considered medications and that residents are not allowed to have medications at the bedside without a current self-administration order, documented assessment, and care plan. When the CNA entered the room during the interview, she identified the bottles as medications and brought them to the RN, who confirmed there was no self-administration order or assessment in the EHR. The DON also confirmed that the facility’s policy requires assessment of mental and physical abilities, documentation of findings, an order, and care plan for self-administration, and that none of these were present for this resident, despite the medication being stored at bedside.
Failure to Maintain Safe 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 monitoring or preventive measures to address 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 the necessary supervision to safeguard residents from potential harm.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Document Staff Interviews During Abuse Investigation
Penalty
Summary
The facility failed to complete a thorough investigation into an allegation of verbal and attempted physical abuse reported by a resident against a nurse. The 5-day investigation documentation showed that only three residents were interviewed, with no documentation of staff interviews. The Director of Nursing stated that standard procedure includes interviewing staff, residents, and other residents, but was on vacation during the incident. The Administrator confirmed that while staff were spoken to, these interviews were not documented. Facility policy requires that all reports of abuse or neglect be promptly and thoroughly investigated, including interviews with staff members on all shifts who had contact with the resident during the alleged incident. The lack of documented staff interviews led to the deficiency.
Failure to Obtain and Document Colostomy Care Orders
Penalty
Summary
The facility failed to ensure that a colostomy care order was in place for a resident who had undergone a total colectomy with ileostomy. Upon review of clinical records, it was found that there were no physician orders for colostomy care or documentation of such care in the resident's care plan or Medication Administration Record. The resident, who had a history of anoxic brain damage, acute respiratory failure, and use of a gastrostomy and tracheostomy tube, was readmitted to the facility after surgery with a colostomy, but the necessary orders for ongoing colostomy care were not present in the electronic health record. Interviews with facility staff, including a CNA, RN, and the DON, confirmed that the resident had a colostomy bag and that standard practice was to check and change the bag regularly. However, staff were unable to locate any formal order for colostomy care in the resident's records. Additionally, documentation revealed inconsistencies in the recording of bowel and bladder checks, with several days showing no data recorded. The facility's policy required that treatments and orders be consistent with safe and effective prescribing principles, but this was not followed in the case of the resident's colostomy care.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including end-stage renal disease, type 2 diabetes with diabetic neuropathy, and chronic heart failure, was left soiled and unattended by a CNA. The incident was observed by another staff member and the resident's former roommate, who reported that the CNA left the resident sitting on the side of the bed with soiled briefs while taking the roommate to lunch. The resident was left in this condition for approximately 30 minutes, during which time the CNA reportedly cursed at the resident. Interviews with staff members, including CNAs and LPNs, revealed that the facility's policy requires residents to be changed promptly when soiled to prevent skin breakdown and ensure comfort. The Director of Nursing and the Administrator confirmed that a 30-minute wait time did not meet their expectations for resident care. The facility's policy on perineal care emphasizes the importance of cleanliness and comfort to prevent infection and skin irritation. Despite the incident, the resident reported feeling safe and well-cared for at the time of the interview, with no resulting skin breakdown.
Failure to Follow Hoyer Lift Protocol Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident was free from preventable falls, resulting in a significant incident during a Hoyer lift transfer. The resident, who was admitted with multiple diagnoses including multiple sclerosis, chronic respiratory failure, and hemiplegia, was found on the floor face down with injuries after a fall during a transfer from a shower gurney back into bed. The resident was cognitively intact and required a mechanical lift device and a two-person assist for transfers, as noted in their care plan. On the day of the incident, the resident was being transferred by a single CNA, contrary to the facility's policy that mandates a two-person assist for Hoyer lift transfers. During the transfer, the Hoyer lift's batteries failed, and the CNA left the resident unattended to retrieve new batteries. Upon returning, the CNA attempted to continue the transfer alone, resulting in the resident falling and sustaining injuries, including a fractured ankle and compression fractures in the lumbar vertebrae. Interviews with staff confirmed that the facility's policy requires two staff members for Hoyer lift transfers to ensure safety and proper positioning of the resident. The CNA involved in the incident admitted to being aware of the policy but chose to proceed alone, leading to the resident's fall and subsequent injuries. The facility's policy and staff interviews highlighted the importance of adhering to the two-person assist requirement to prevent such incidents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 123 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tucson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Handmaker Home For The Aging | 0 mi | ★★★★★ | 12 | 1 |
| Sabino Canyon Rehabilitation & Care Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Santa Rosa Care Center | 0.7 mi | ★★★★★ | 20 | 0 |
| Pueblo Springs Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| The Center At Tucson | 0.9 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.