Inspection visit
Inspection
Citations
22 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0004GeneralS&S Epotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0009GeneralS&S Epotential for harm
Include a process for Emergency Preparedness collaboration.
- 0018GeneralS&S Epotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0022GeneralS&S Epotential for harm
Establish policies and procedures for sheltering.
- 0023GeneralS&S Epotential for harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Epotential for harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Epotential for harm
Establish roles under a Waiver declared by secretary.
- 0029GeneralS&S Epotential for harm
Develop a communication plan.
- 0033GeneralS&S Epotential for harm
Establish methods for sharing information.
- 0034GeneralS&S Epotential for harm
Provide a means of sharing information on occupancy/needs.
- 0341GeneralS&S Dpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0345GeneralS&S Epotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the March 7, 2025 survey of FOOTHILLS REHABILITATION CENTER?
This was a inspection survey of FOOTHILLS REHABILITATION CENTER on March 7, 2025. The surveyor cited 22 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FOOTHILLS REHABILITATION CENTER on March 7, 2025?
Yes, 22 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.