Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 5 | 0 |
| Sabino Canyon Rehabilitation & Care Center | 0.8 mi | — | 3 | 0 |
| Pueblo Springs Rehabilitation Center | 0.9 mi | — | 0 | 0 |
| Foothills Rehabilitation Center | 1.2 mi | — | 12 | 0 |
| Handmaker Home For The Aging | 1.2 mi | — | 12 | 1 |
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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 August 2026) and official state health department websites.