Inspection Reports for
Sabino Canyon Rehabilitation and Care Center

The complaint investigation found that Resident #32 was discharged a day before the planned discharge date despite filing an appeal against the discharge. The appeal was successful, but the resident was not informed she could stay during the appeal process and felt forced to leave. The facility staff acknowledged the discharge was premature and lacked documentation explaining the early discharge. The facility policy states residents should not be discharged while an appeal is pending unless health or safety is endangered.

The facility failed to ensure Resident #32 was allowed to remain at the facility during the appeal of a Notice of Medicare Non-Coverage (NOMNC), resulting in the resident being discharged a day early without proper notification or documentation. Interviews and record reviews confirmed the resident was unaware she could stay during the appeal and the facility did not follow its own discharge policy.

The facility failed to ensure Resident #32 was not discharged prematurely during a Medicare Non-Coverage appeal, resulting in potential harm due to lack of proper notification and support. Interviews and record reviews confirmed the resident was discharged a day early without documentation of voluntary discharge, despite policy stating residents should not be discharged while an appeal is pending.

The complaint alleged neglect due to resident #100 leaving the facility without being reported missing, resulting in injury. The resident was found by the fire department after a fall outside the facility. The investigation confirmed the resident was at high risk for elopement and that staff failed to adequately supervise and respond to the incident.

The facility failed to ensure resident #100 was free from preventable accidents including elopement, resulting in the resident leaving the facility unnoticed, sustaining injuries, and requiring hospitalization. The investigation revealed inadequate supervision, malfunctioning wander guards, and failure to initiate proper elopement protocols.

The complaint was substantiated based on review of records, staff interviews, and the State Agency complaint tracking system. It was confirmed that Resident #11 was discharged without the ordered wheelchair, which was left at the facility. The fire department responded to assist the resident at home due to lack of mobility equipment.

The facility failed to ensure that Resident #11 received the ordered wheelchair at discharge, resulting in the resident being sent home without the necessary equipment, which posed a risk to the resident's safety and well-being. The wheelchair was left at the facility and later picked up by the fire department after a call for assistance.

The complaint investigation focused on water leaks throughout the facility causing unsafe conditions and medication supervision failures. The complaint was substantiated with findings of ongoing leaks, resident reports, and staff interviews confirming maintenance issues and medication errors.

The facility failed to maintain a safe, clean, and homelike environment due to multiple water leaks from the ceiling and windows, resulting in wet ceilings, water stains, musty odors, and potential mold concerns affecting numerous residents. Additionally, there was a failure to ensure adequate supervision to prevent medication accidents and improper food storage practices.

The facility failed to maintain a safe, clean, and homelike environment due to ongoing water leaks from the roof and ceilings affecting multiple resident rooms, resulting in potential hazards and discomfort. Additionally, the facility failed to ensure adequate supervision to prevent medication accidents for one resident and did not follow proper sanitary practices in the kitchen.

The investigation was complaint-driven, focusing on grievances about missing personal items, medication administration errors, pressure ulcer care deficiencies, unnecessary drug administration, missing or incorrect advanced directives, and infection control breaches during glucose testing.

The facility was found deficient in multiple areas including failure to promptly resolve a resident grievance about missing clothing, failure to administer medications as ordered, inadequate pressure ulcer care, administration of unnecessary medications, lack of proper advanced directive documentation, and failure to follow infection control protocols during point-of-care glucose testing.

The facility was found deficient in several areas including failure to promptly resolve a resident grievance regarding missing clothing, failure to administer physician-ordered medications, inadequate pressure ulcer treatment and documentation, administration of unnecessary medications outside physician parameters, lack of proper advanced directive documentation for residents, and failure to follow infection control protocols during point-of-care glucose testing.