Inspection Reports for
Sabino Canyon Rehabilitation and Care Center

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 investigation revealed that on February 2, 2024, a fire district department responded to assist Resident #11 who was sent home without a wheelchair and was unable to walk independently. The resident's wheelchair was left at the facility and was later picked up by the fire department. The facility acknowledged the failure to provide the wheelchair at discharge despite having an order and delivery arranged.

The facility failed to ensure that Resident #11 received a wheelchair, as ordered by the provider, at the time of discharge. This deficiency posed a risk to the resident's medical, physical, and psychosocial well-being at home. The wheelchair was left at the facility and only delivered later by the fire department after a call for assistance.

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.

State compliance survey citing 6 deficiencies related to safe environment, accidents, food safety, care plans, kitchen sanitation, and premises safety.

Recertification survey for Medicare under Life Safety Code citing 2 fire safety deficiencies.

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.