Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Pueblo Springs Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was physically pushed by another resident in a hallway. Staff intervened immediately and assessed the resident, finding no injury. Interviews and documentation confirmed the incident and highlighted a failure to prevent resident-to-resident abuse as required by facility policy.
A resident with a suprapubic catheter and diabetic ulcer, both requiring enhanced barrier precautions, was cared for by an LPN who exited the room wearing gloves and placed a device back into the medication cart without removing PPE or performing hand hygiene as required. Staff interviews revealed inconsistent understanding and application of enhanced barrier precautions, with some staff not using gowns when obtaining blood sugar levels despite facility policy and signage. This resulted in a failure to ensure proper infection prevention and control practices.
A resident admitted with cellulitis did not have an inventory sheet completed for their personal belongings, despite facility policy and staff expectations requiring this documentation during the admission process. Staff interviews confirmed the inventory process was not followed, and the administrator was unable to provide the required documentation when requested.
A resident with a history of mental health and substance use disorders experienced multiple behavioral incidents, including altercations and suspected intoxication, but the facility failed to update the PASRR to reflect these changes or review recommendations as required. Staff interviews and documentation confirmed the PASRR remained outdated and inaccurate, listing discontinued medications and omitting current behavioral concerns.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse by another resident. The incident occurred in a hallway, where a resident with quadriplegia and multiple comorbidities, including dementia and severe cognitive impairment, was sitting in a wheelchair. Another resident, while ambulating with therapy staff, accused the first resident of attempting to trip him and responded by pushing the resident in the shoulder. Staff immediately separated the residents, and an assessment found no injury. Notifications were made to the family, provider, and ombudsman. Clinical record reviews, interviews, and facility documentation confirmed that the resident was vulnerable due to impaired cognition and was at risk for abuse. Staff interviews indicated an understanding of abuse protocols, including immediate intervention and reporting. However, the event demonstrated a failure to prevent resident-to-resident physical abuse, as required by facility policy and federal regulations. The deficiency was identified through review of the incident, resident and staff interviews, and policy review.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow appropriate infection control practices for a resident with significant risk factors, including a suprapubic catheter and a diabetic ulcer, both requiring enhanced barrier precautions. During an observation, an LPN exited the resident's room wearing gloves and holding a device, which was then placed back into the medication cart, despite the presence of an Enhanced Barrier Precaution sign on the door. The LPN acknowledged the expectation to dispose of personal protective equipment (PPE) within the resident's room and to perform hand hygiene before and after resident care, but did not follow these protocols during the observed event. Interviews with facility staff revealed inconsistent understanding and application of enhanced barrier precautions. The LPN stated that only gloves were necessary when obtaining blood sugar levels, even when enhanced barrier precautions signage was present. In contrast, a CNA indicated that both gloves and gowns should be worn for care under enhanced barrier precautions, and that all PPE should be removed and disposed of in the resident's room, with hand hygiene performed before and after care. The Infection Preventionist and Wound Care Nurse further clarified that a gown is required when checking blood sugars for residents under enhanced barrier precautions, due to potential exposure to blood. The Director of Nursing confirmed that staff are expected to follow signage and use appropriate PPE, such as gloves and gowns, when performing tasks that may expose them to blood or bodily fluids. Facility policy also requires proper PPE use when care exposes staff to blood and bodily fluids. The observed failure to remove gloves before exiting the room and the inconsistent application of enhanced barrier precautions among staff contributed to the deficiency in infection prevention and control practices.
Failure to Complete Resident Inventory Documentation at Admission
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent the misappropriation of a resident's property. Specifically, upon admission of a resident diagnosed with cellulitis of the left lower limb, staff did not complete an inventory sheet documenting the resident's personal belongings. When a request was made to review the inventory sheet, the administrator confirmed that no such documentation existed for the resident and was unsure of the circumstances on the day of admission. Interviews with facility staff revealed that the expected process during admission includes creating a detailed inventory sheet of the resident's belongings, which should be completed within a specified timeframe. The facility's policy requires that an inventory of personal effects be conducted and documented at admission, with signatures from the resident, responsible party, and staff, and a copy provided to the resident. Despite these established procedures, the required inventory was not completed for this resident, resulting in a failure to follow policy and a lack of documentation regarding the resident's property.
Failure to Update PASRR Following Resident Behavioral Changes
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) for a resident was updated to accurately reflect changes in the resident's condition. The resident, who had a history of alcoholic cirrhosis, major depressive disorder, insomnia, and a prior myocardial infarction, experienced several behavioral incidents, including altercations with other residents, verbal aggression, and suspected alcohol intoxication. Despite these significant changes and ongoing behavioral health concerns, the PASRR was not revised to include substance-related disorders or issues with interpersonal behaviors, and it continued to list a discontinued medication as active. Documentation showed that the resident had multiple behavioral incidents over several months, including altercations, irritability, and verbal aggression. Progress notes and care plans indicated interventions for ineffective coping related to alcohol abuse and referrals for mental health support. However, the facility's interdisciplinary team did not review or update the PASRR recommendations in response to these changes, and the most recent PASRR on file was outdated and inaccurate. Interviews with staff, including the admissions director and DON, confirmed that the PASRR was not current and did not reflect the resident's present status or needs. Facility policies required the IDT to review PASRR recommendations and to update documentation following significant changes in a resident's condition, but there was no evidence that these procedures were followed in this case.
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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) |
|---|---|---|---|---|
| Sabino Canyon Rehabilitation & Care Center | 0.1 mi | ★★★★★ | 3 | 0 |
| Handmaker Home For The Aging | 0.7 mi | ★★★★★ | 12 | 1 |
| Sandstone Estates Rehab Centre | 0.7 mi | ★★★★★ | 5 | 0 |
| Foothills Rehabilitation Center | 0.8 mi | ★★★★★ | 26 | 0 |
| Devon Gables Rehabilitation Center | 0.9 mi | ★★★★★ | 1 | 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.