Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sabino Canyon Rehabilitation & Care Center during CMS and state inspections, most recent first.
Delayed Documentation of Advance Directive and Code Status: A resident who was alert and able to communicate had no advance directive/code status documented at admission, despite facility policy requiring it to be obtained and recorded upon admission. The resident later stated a full-code preference, and the form and physician order were completed afterward, but the care plan still did not reflect the resident’s advance directive/code status. Staff interviews confirmed the delay and showed differing views on whether the timing and documentation were compliant with policy.
Transfer and discharge documentation not completed for a hospital transfer. A resident with multiple diagnoses and severe cognitive impairment became non-responsive and was sent to the hospital, with family and the attending service notified and belongings later picked up by the family. However, the record lacked a physician order for the transfer, no transfer assessment was completed, and no discharge MDS was initiated or completed, despite staff and DON statements that these documents were required.
A resident with multiple diagnoses, including severe cognitive impairment, was transferred to the hospital for altered mental status and non-responsiveness, but the facility did not complete the required discharge MDS. Record review found no discharge MDS at first, and staff later acknowledged that the assessment had not been completed for the resident’s hospital transfer, despite facility policy requiring accurate assessment and discharge documentation.
Incomplete MDS and Medication Documentation: The facility failed to keep resident records accurate for two residents. One resident’s record did not reflect depression even though Sertraline was ordered for depression and staff said the diagnosis should have been listed. Another resident had multiple Hydromorphone doses removed from the cart for scheduled pain control, but those doses were not documented on the MAR even though staff said the medication should be recorded in both the narcotics book and MAR.
A CNA failed to follow infection control practices while obtaining vital signs for residents on EBP. She entered resident rooms without hand hygiene, used the same blood pressure cuff and pulse oximeter on multiple residents without sanitizing the equipment between uses, did not wear a gown and gloves in an EBP room, and exited rooms without performing hand hygiene. The DON confirmed that facility policy required sanitizing reusable equipment after each use and wearing gown and gloves for direct care in EBP rooms.
A resident with multiple orthopedic and neurologic conditions was transferred to another facility after a referral, insurance authorization, and acceptance were documented, and a discharge MDS indicated the resident’s return was not anticipated and that she was cognitively independent. Although staff described a process in which nursing and social services complete discharge summaries with information on home health, DME, follow-up providers, and contact information, they reported that they do not complete discharge summaries or document them in the chart when a resident transfers to another facility, instead sending clinical information and orders as a transfer packet. The MDS coordinator confirmed that this situation met the definition of a discharge and that no discharge summary was present in the record, and leadership acknowledged there was no facility policy specifically addressing discharge summaries.
A resident with dementia and a history of falls and wandering exited the facility unsupervised, resulting in a fall and injuries. Despite care plans indicating high risk and the need for interventions such as 1:1 supervision and a wander guard, staff were unaware the resident was missing, no elopement alert was called, and only one door had a functioning wander guard. The resident was found by emergency services outside the facility, and staff interviews revealed issues with supervision, staffing, and malfunctioning safety devices.
Delayed Documentation of Advance Directive and Code Status
Penalty
Summary
The facility failed to ensure that the advance directive/code status for one resident was recorded in the medical record in a timely manner. Resident #133 was admitted with diagnoses including surgical aftercare of the nervous system, type 2 diabetes mellitus, post-polio syndrome, and a personal history of benign neoplasm. On admission, the resident was verbally communicative, had clear speech, and was able to understand and be understood, but the admission documentation did not show that the resident’s advance directive or code status preference had been obtained or documented at that time. A physician later documented speaking with the resident about end-of-life care, and the resident stated she wanted to be resuscitated if she developed cardiopulmonary arrest. The advance directive form was completed the next day and showed full-code status, and a physician order reflecting full-code status was entered into the EHR the following day by the DON. A BIMS completed several days later showed a score of 14, indicating intact cognitive function. The care plan contained no evidence of the resident’s code status or advance directive preferences. Interviews with staff showed the facility expected advance directive/code status preferences to be obtained upon admission, and that if no directive was on file the resident would be treated as full code until an order was entered. The RN stated the resident’s advance directive/code status should have been obtained upon admission and documented in the care plan, and that the delay in obtaining and entering it was not in compliance with facility policy. The DON stated the information was secured upon admission by the admission nurse, but also acknowledged that the resident’s code status was not always updated on the care plan and that the delay in obtaining and uploading the resident’s advance directive/code status preference was compliant with facility policy. The facility policy required advance directive preferences to be asked about at admission, confirmed in the medical record, documented in the plan of care, and communicated to the attending physician so appropriate orders could be documented.
Transfer and discharge documentation not completed for hospital transfer
Penalty
Summary
The facility failed to execute and document the transfer/discharge process for one resident who was sent to an acute care hospital after becoming non-responsive and only responsive to tactile stimuli. The resident had multiple diagnoses, including a displaced fracture of the left femur neck, muscle weakness, hypertension, hyperlipidemia, obstructive and reflux uropathy, cognitive communication deficit, polyneuropathy, and severe cognitive impairment as reflected by a BIMS score of 7. The resident’s record showed a nursing progress note documenting the hospital transfer and that the family and attending answering service were notified. Another progress note documented that the resident’s son and his wife later picked up the resident’s belongings from the facility. However, review of the clinical record found no evidence that a discharge MDS was initiated or completed at the time of the transfer, and there was no evidence of a physician’s order to transfer the resident to the hospital. Interviews with nursing and MDS staff confirmed that the facility expected a physician’s order, a transfer assessment, documentation of the transfer, and completion of a discharge MDS when a resident was sent to the hospital. The DON also stated that the facility did not complete a transfer form or obtain a physician’s order for the transfer and that the discharge MDS was not completed. Facility policy required transfer or discharge documentation in the medical record and communication of appropriate information to the receiving provider.
Incomplete Discharge MDS After Hospital Transfer
Penalty
Summary
The facility failed to ensure that Resident #3’s discharge MDS assessment was completed and accurate after the resident was transferred to an acute care hospital. Resident #3 was admitted with diagnoses including displaced fracture of the left femur neck, muscle weakness, displaced supracondylar fracture, hypertension, hyperlipidemia, obstructive and reflux uropathy, cognitive communication deficit, polyneuropathy, and muscle weakness. An admission MDS showed a BIMS score of 7, indicating severe cognitive impairment. Resident #3’s record showed a discharge date of February 22, 2026, and nursing documentation stated that the resident was transferred to the hospital that morning due to altered mental status and being non-responsive to verbal stimuli, responding only to tactile stimuli. The note also documented that the family and son were notified by phone and that the attending answering service was updated. A later progress note documented that the resident’s son and his wife picked up the resident’s belongings from the facility. Review of the clinical record on June 26, 2026, found no evidence that a discharge MDS had been initiated or completed. A later review showed a discharge MDS was initiated and in progress that day, with multiple sections completed after an interview with the MDS assistant. During interviews, the RN, MDS assistant, and DON all stated that a discharge MDS was required when a resident transferred to the hospital and acknowledged that it had not been completed for Resident #3. Facility policies also stated that assessments must accurately reflect the resident’s status and that transfer or discharge documentation must include the basis for the transfer and related information.
Incomplete MDS and Medication Documentation
Penalty
Summary
The facility failed to ensure that resident medical records were completed accurately for two residents regarding MDS assessment information and pain medication documentation. The deficiency was identified through clinical record review, staff interviews, and policy review, and involved inaccurate or incomplete documentation in the resident medical records. For one resident, the admission MDS submitted to CMS showed a BIMS score of 15 and indicated no cognitive impairment, while also showing rejection of care and several active diagnoses. Subsequent MDS submissions also showed no diagnosis of depression. However, the resident was prescribed Sertraline HCL for depression as evidenced by negative statements, and the MAR did not list depression as a diagnosis until the DON entered it into the electronic health record much later. The resident stated she was aware she was taking Sertraline for depression and negativity and participated in care plan meetings where medications were reviewed. The DON stated depression should have been listed, and the MDS Assistant stated that if a resident is taking Sertraline for depression, the diagnosis should be in the medical record and on the MAR. For the second resident, the record showed a diagnosis of multiple chronic conditions, including dementia, depression, and mood disorder, and the resident had an order for Hydromorphone HCL 2 mg every 8 hours for pain. Review of the narcotics sheets showed multiple occasions when Hydromorphone was removed from the medication cart, but those doses were not documented on the MAR. Staff interviews confirmed that scheduled pain medication should be documented in both the narcotics book and the MAR, and the DON acknowledged that the MAR was not documented for Hydromorphone when the chart was reviewed. Facility policies reviewed included requirements for accurate medication documentation, complete charting, accurate MDS assessment, and use of psychoactive medication only with a specific physician order and diagnosis-specific condition.
Failure to Sanitize Reusable Equipment and Follow EBP PPE Requirements
Penalty
Summary
The facility failed to maintain infection control standards when a CNA used reusable medical equipment to obtain vital signs for residents who were on Enhanced Barrier Precautions (EBP). During an observation in a resident room occupied by two residents, the CNA entered without performing hand hygiene, used the same blood pressure cuff and pulse oximeter on both residents, and did not sanitize either device between uses. After each resident assessment, the CNA removed the blood pressure cuff and hung it on the cart and placed the pulse oximeter in her pocket without cleaning either item. The CNA also did not perform hand hygiene after assessing the residents and was observed applying lip balm from her pocket while in the room. The CNA then moved the blood pressure cart to another resident’s room that also had an EBP sign posted outside. She again entered without hand hygiene, did not don a gown and gloves, and did not sanitize the blood pressure cuff or pulse oximeter before use. She used the same equipment to obtain the resident’s vital signs, then removed the devices without sanitizing them and exited the room without performing hand hygiene. The CNA later confirmed that she did not sanitize the equipment between resident uses and stated that facility policy required the blood pressure cuff and pulse oximeter to be sanitized between each use with bleach wipes. The CNA also confirmed that she was not wearing a gown or gloves in the EBP room and stated that facility policy required a gown and gloves when providing care in EBP rooms. The DON stated that reusable medical devices such as blood pressure cuffs and pulse oximeters must be sanitized after each resident use and that gowns and gloves must be worn in EBP rooms during direct care. Facility policy stated that the IPCP includes proper PPE use, hand hygiene, environmental cleaning and disinfection, and reprocessing of reusable medical equipment, and that a gown and gloves must be used during high-contact resident care activities for residents on EBP.
Failure to Complete Discharge Summary for Non-Return Anticipated Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to complete a discharge summary for one resident whose discharge was not anticipated to return. The resident was admitted with diagnoses including left foot drop, left wrist drop, and a fracture of the lower end of the left radius. A discharge MDS indicated that the resident’s return was not anticipated and that she was cognitively independent for daily decision-making. Progress notes showed that on December 10, 2025, a referral was sent to another facility at the request of a family member, and on December 11, 2025, the receiving facility obtained insurance authorization and accepted the resident, with transfer scheduled for December 12, 2025. A final progress note on December 12, 2025 documented that a report was called to the receiving facility and the resident was sent with her belongings and medications. Further review of the clinical record did not reveal a discharge summary for this resident. During interviews, social services staff stated that discharge summaries are completed by nursing and social services and include information such as home health agencies, DME needs, future provider appointments, Ombudsman contact, and facility contact information, but that they do not complete discharge summaries for residents who transfer to another facility and do not document anything in the chart in those cases. The MDS coordinator/LPN confirmed that, based on the MDS indicating the resident’s return was not anticipated, this situation should be considered a discharge and that no discharge summary could be located. The Social Services Director described a discharge as leaving to go home and a transfer as moving to another facility, and explained that discharge summaries are only done when a person is discharging to their place of residence, with transfer information instead communicated by nursing report. When surveyors requested a discharge summary policy, the administrator reported that the facility did not have one, and the existing Discharge Planning Process policy did not contain language about a resident discharge summary.
Failure to Prevent Resident Elopement and Injury Due to Inadequate Supervision and Safety Measures
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was free from preventable accidents, including elopement. The resident, who had multiple diagnoses such as vascular dementia, diabetes, and a history of falls, was identified as high risk for both falls and elopement. Despite care plans indicating the need for interventions such as 1:1 supervision as staffing allows, use of a wander guard, and placement in a high-traffic area, the resident was able to leave the facility unsupervised. Documentation shows that the resident had a history of wandering and delusional behavior, including expressing intentions to go to a casino, and had previously experienced multiple falls. On the day of the incident, the resident exited the facility without staff knowledge and was found by emergency services outside the facility after sustaining a fall, which resulted in injuries including a left knee skin tear and a right arm fracture. Staff interviews revealed that no code yellow (elopement alert) was called because staff were unaware the resident was missing. Several staff members described the resident as confused, delusional, and frequently wandering, with some staff noting that the facility was short-staffed on the day of the incident. Maintenance staff reported that only the front door had a working wander guard, while other doors had generic alarms, and some wander guard systems were not functioning properly. Facility documentation and staff interviews confirmed that the resident's elopement was not immediately detected, and the resident was not reported missing until after being found by emergency responders. The facility's policies required appropriate assessment, interventions, and supervision to prevent accidents related to unsafe wandering or elopement, but these measures were not effectively implemented for this resident. The lack of timely detection and response to the resident's absence, combined with inadequate functioning of safety devices and insufficient supervision, directly contributed to the resident's elopement and subsequent injuries.
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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) |
|---|---|---|---|---|
| Pueblo Springs Rehabilitation Center | 0.1 mi | ★★★★★ | 1 | 0 |
| Handmaker Home For The Aging | 0.7 mi | ★★★★★ | 7 | 0 |
| Sandstone Estates Rehab Centre | 0.7 mi | ★★★★★ | 9 | 0 |
| Foothills Rehabilitation Center | 0.7 mi | ★★★★★ | 26 | 0 |
| Devon Gables Rehabilitation Center | 0.8 mi | ★★★★★ | 3 | 0 |
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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 October 2026) and official state health department websites.