Inspection Reports for
Sabino Canyon Rehabilitation and Care Center

An onsite complaint investigation was conducted on February 24, 2026 for intake #00159758. There were no deficiencies cited.

This inspection resulted in no deficiencies cited.

The complaint survey was conducted on December 29, 2025, with the investigation of intake #00152618 and intake #2687055. No deficiencies were cited.

No deficiencies were found during this complaint investigation.

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 inspection found two deficiencies related to maintenance of the sprinkler system and corridor doors. Both deficiencies had plans of correction provided.

An onsite complaint survey was conducted on July 14 through July 15, 2025 for the investigation of intake #00136371, 00136371. There were no deficiencies cited. An onsite complaint survey was conducted on July 14 through July 15, 2025 for the investigation of intake #2561632, 2561741. There were no deficiencies cited.

This inspection resulted in no deficiencies cited or citations.

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 onsite investigation of intakes 00129802, 00130609, AZ00213584, AZ00213582, AZ00224464, AZ00224514, AZ00213393, and AZ00213582 was conducted on May 20, 2025. No deficiencies were cited.

No deficiencies were cited during this complaint investigation.

The onsite investigation of intake SF00123144 and intake AZ00223854 was conducted on March 25, 2025. No deficiencies were cited.

No deficiencies were cited during this inspection.

An onsite complaint survey was conducted on March 10, 2025 through March 11, 2025 for the investigation of intake # 00121651, 00121078. Federal comments note investigation of intake # AZ00223714, AZ00223663. There were no deficiencies cited.

This inspection resulted in no deficiencies cited.

An onsite complaint survey was conducted on February 25, 2025 for the investigation of intake # AZ00223489. There were no deficiencies cited.

No deficiencies were cited during this inspection.

An onsite complaint survey was conducted on February 4 through February 5, 2025 for the investigation of intakes# AZ00222348, AZ00221604, AZ00183100, AZ00168182, AZ00166425, AZ00164820, AZ00163922, AZ00163537. There were no deficiencies cited.

No deficiencies were cited during this complaint investigation.

An onsite complaint survey was conducted on January 9, 2025 for the investigation of intake # AZ00221391. There were no deficiencies cited.

No deficiencies were cited during this complaint investigation.

A complaint survey was conducted on September 30, 2024 for the investigation of intake # AZ00216541 and AZ00216438. There were no deficiencies cited. A complaint survey was conducted on September 30, 2024 for the investigation of intake # AZ00216537 and AZ00216438. There were no deficiencies cited.

This inspection found no deficiencies.

An onsite complaint survey was conducted on September 4, 2024 for the investigation of intake #AZ00215356, AZ00215324, and AZ00215355. No deficiencies were cited.

No deficiencies were cited during this complaint investigation.

The investigation of complaint #AZ00214439 was conducted on August 13. 2024. The investigation of complaint #AZ00214442 was conducted on August 13. 2024. There were no deficiencies cited.

This inspection found no deficiencies.

The complaint survey was conducted on July 15, 2024 through July 16, 2024 for the investigation of intake #s AZ00183208, AZ00180381, and AZ00163880. No deficiencies were cited.

No deficiencies were cited during this complaint investigation.

An onsite complaint survey was conducted on June 27, 2024 for the investigation of intake # AZ00212222. An onsite complaint survey was conducted on June 27, 2024 for the investigation of intake # AZ00212219. There were no deficiencies cited.

This inspection resulted in no deficiencies cited.

An onsite complaint investigation was conducted on June 17, 2024 for the following intakes: AZ00211517, AZ00211751, AZ00211515 and AZ00211750. There were no deficiencies cited.

No deficiencies were cited during this inspection.

The complaint survey was conducted on November 20, 2023 for the investigation of intake #AZ00203280, AZ00203169, and AZ00203279. No deficiencies were cited.

No deficiencies were cited during this complaint investigation.

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 inspection identified six deficiencies related to environmental safety, medication supervision, food safety, care planning, food storage, and premises safety. Plans of correction were provided for all deficiencies.

Two deficiencies were cited related to fire safety equipment accessibility. The facility failed to keep fire alarm pull stations and portable fire extinguishers unobstructed, which could delay emergency response.

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 complaint survey was conducted on August 9, 2023 for the investigation of intake #s: AZ00198465, AZ00198468, AZ00198416, AZ00198611, AZ00198463, AZ00198466, AZ00198412 and AZ00198612. No deficiencies were cited.

No deficiencies were cited during this complaint investigation.

An onsite survey was conducted on July 13, 2023 for the investigation of intake #AZ00197259. A complaint survey was conducted on July 13, 2023 for the investigation of intake #AZ00197258. No deficiencies were cited.

No deficiencies were found during this complaint investigation.

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.

No health deficiencies were found during the inspection.

No health deficiencies were found during the survey.