Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 146 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 0 | 0 |
| Handmaker Home For The Aging | 0.7 mi | ★★★★★ | 12 | 1 |
| Sandstone Estates Rehab Centre | 0.7 mi | ★★★★★ | 5 | 0 |
| Foothills Rehabilitation Center | 0.7 mi | ★★★★★ | 26 | 0 |
| Devon Gables Rehabilitation Center | 0.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.