27 Reports
Inspection Report — Feb 11, 2026
Date: Feb 11, 2026
Visit Reason
On-site inspection of type Other with Nursing Care Institution worksheet at Life Care Center of Tucson conducted 11 February 2026.
Findings
This inspection found no deficiencies or citations.
Inspection Report — Nov 24, 2025
Complaint Investigation
Date: Nov 24, 2025
Visit Reason
On-site complaint investigation of multiple complaints including 00154040, 00155150, 00160000, 00160558, 00160896, 00161064, 00168844, 00170106, 00173724, 00174119, 00174381, 00174425, 00176431, 00179389, 00180059, 00180113, 00180124, and 00181471 at a Nursing Care Institution, conducted 24 November 2025.
Complaint Details
The Risk-Based complaint survey was conducted on October 14, 2022 through October 23, 2025 for investigation of intake #s: 00154040, 00155150, 00160000, 00160558, 00160896, 00161064, 00168844, 00170106, 00173724, 00174119, 00174381, 00174425, 00176431, 00179389, 00180059, 00180113, 00180124, 00181471. There were no deficiencies identified.
Findings
This inspection found no deficiencies.
Inspection Report — Sep 18, 2025
Complaint Investigation
Date: Sep 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate assessment, monitoring, and supervision to prevent elopement for one of the sampled residents.
Complaint Details
The complaint investigation found that resident #119, initially not assessed as at risk for elopement, was later identified as high risk following a condition change on August 28, 2025. Despite updated care plans and interventions, the resident eloped on August 30, 2025, exiting through the front door after 4 PM, reportedly with assistance from the receptionist. The facility did not have Wander Guards or security cameras, and staff monitoring was insufficient to prevent the incident. The resident was found by a sheriff deputy and returned safely.
Findings
The facility failed to adequately protect a resident (#119) who was identified as at risk for elopement after a condition change but subsequently exited the facility unsupervised through the front door, reportedly assisted by the receptionist. The facility lacked Wander Guards and security cameras, and monitoring protocols were inconsistently applied.
Deficiencies (1)
Failure to ensure adequate assessment, monitoring, and supervision to prevent elopement for one resident.
Report Facts
Residents sampled: 5
Resident BIMS score: 4
Date of elopement incident: Aug 30, 2025
Number of facility entrances: 4
Frequency of checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #36 | Licensed Practical Nurse | Interviewed regarding elopement risk assessments and monitoring procedures |
| CNA #22 | Certified Nursing Assistant | Interviewed about monitoring residents and presence during resident #119's admission |
| Director of Nursing (DON) Staff #100 | Director of Nursing | Interviewed about elopement risk assessments, monitoring, and incident details |
Inspection Report — Aug 15, 2025
Complaint Investigation
Date: Aug 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of medication misappropriation and improper medication administration practices involving controlled substances and other medications at Life Care Center of Tucson.
Complaint Details
The complaint investigation was substantiated, revealing that Staff #120 diverted medications including Fentanyl patches, Ozempic, Mounjaro, Morphine, and Dilaudid. The facility submitted a complaint to the Arizona Board of Nursing (AZBON) and Staff #120 was suspended and terminated. The investigation included review of controlled substance records, medication administration records, interviews with staff, and policy reviews.
Findings
The facility failed to ensure medications were properly administered and controlled, resulting in misappropriation of controlled substances including Fentanyl patches, Morphine, Dilaudid, and unauthorized medication orders. Multiple residents were affected by medication diversion, inaccurate narcotic counts, and improper documentation by nursing staff, particularly Staff #120, who was suspended and terminated following the investigation.
Deficiencies (2)
Failure to protect residents from wrongful use of their belongings or money, specifically misappropriation of controlled substances by nursing staff.
Failure to provide appropriate treatment and care according to physician orders, resulting in residents not receiving medications as ordered and possible medication diversion.
Report Facts
Residents affected: 4
Medication doses missing: 4.25
Medication doses missing: 6.25
Medication doses missing: 17
Medication doses missing: 25
Medication administration failures: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #120 | Licensed Practical Nurse (LPN) | Named in multiple medication diversion and improper medication administration findings. |
| Staff #67 | Assistant Director of Nursing (ADON) | Provided explanations and expectations regarding medication tracking and ordering. |
| Staff #108 | Licensed Practical Nurse (LPN) | Explained controlled substance storage and medication ordering processes. |
| Staff #97 | Licensed Practical Nurse (LPN) | Explained controlled substance management and medication ordering procedures. |
| Staff #51 | Registered Nurse (RN) | Reported missing Fentanyl patch and involved in investigation. |
Inspection Report — Mar 26, 2025
Complaint Investigation
Date: Mar 26, 2025
Visit Reason
On-site complaint investigation of intakes SF00123855 and AZ00223909 at a Nursing Care Institution, conducted 26 March 2025.
Complaint Details
The onsite investigation of intake SF00123855 and intake AZ00223909 was conducted on March 26, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Mar 10, 2025
Complaint Investigation
Date: Mar 10, 2025
Visit Reason
On-site complaint investigation of intakes 00121671, 00121127, AZ00223712, and AZ00223669 at a Nursing Care Institution, conducted 10 March 2025.
Complaint Details
An onsite complaint survey was conducted on March 10, 2025 for the investigation of intake # 00121671, 00121127. There were no deficiencies cited. An onsite complaint survey was conducted on March 10, 2025 for the investigation of intake # AZ00223712, AZ00223669. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 4
Inspection Report — Jan 29, 2025
Complaint Investigation
Date: Jan 29, 2025
Visit Reason
On-site complaint investigation of intakes AZ00221923 and AZ00222024 at a Nursing Care Institution, conducted 28 and 29 January 2025.
Complaint Details
An onsite complaint survey was conducted on January 28, 2025 and January 29, 2025 for the following intakes: AZ00221923 and AZ00222024. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Sep 20, 2024
Complaint Investigation
Date: Sep 20, 2024
Visit Reason
On-site complaint investigation of complaints AZ00216188, AZ00216064, AZ00216187, AZ00216063 and AZ00215914 at a Nursing Care Institution, conducted 20 September 2024.
Complaint Details
An onsite complaint survey was conducted on September 20, 2024 for the investigation of complaint #AZ00216188 and AZ00216064. An onsite complaint survey was conducted on September 20, 2024 for the investigation of complaint #AZ00216187,AZ00216063 and AZ00215914. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 5
Inspection Report — Aug 20, 2024
Enforcement
Date: Aug 20, 2024
Visit Reason
Civil monetary penalty, action 00110748 (invoice INV-257682), assessed 20 August 2024.
Findings
A $48,000.00 penalty was assessed and paid in full on 21 November 2024.
Report Facts
Penalty amount: 48000
Amount paid: 48000
Amount remaining: 0
Inspection Report — Jul 17, 2024
Annual Inspection
Date: Jul 17, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, specifically focusing on assistance with bathing for residents.
Findings
The facility failed to ensure that one resident (#6) consistently received assistance with bathing as required by their care plan, which could result in poor hygiene and skin infections. Documentation and interviews revealed multiple instances where bathing did not occur or was refused without proper documentation.
Deficiencies (1)
Failure to provide assistance with bathing to resident #6 as required by care plan, risking poor hygiene and skin infections.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding bathing documentation and facility expectations |
Inspection Report — Jul 17, 2024
Routine
Date: Jul 17, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, safety, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including inaccurate completion of Advanced Beneficiary Notices, failure to maintain safe and comfortable ambient temperatures during a power outage, failure to conduct timely resident weights, inaccurate nurse staffing postings, unsafe food storage temperatures, incomplete tuberculosis screening for staff, inadequate emergency power system functioning, unsafe and uncomfortable physical environment conditions, and incomplete annual staff training.
Deficiencies (9)
Failure to ensure accurate and complete Advanced Beneficiary Notices for residents #222 and #223.
Failure to maintain adequate and comfortable temperature levels for 14 residents during a power outage and cooling system failure.
Failure to conduct initial and ongoing weights for resident #36 as per facility policy.
Failure to post accurate daily nurse staffing information including actual hours worked.
Failure to maintain walk-in refrigerator temperatures consistently below 40°F, risking food safety.
Failure to ensure tuberculosis testing was completed prior to employment for staff #110 (Administrator).
Failure of emergency generator to automatically start during power outage on July 14, 2024, resulting in loss of power and non-functioning critical systems.
Unsafe and uncomfortable physical environment including peeling paint, rough and gouged handrails, protruding nails and screws, and metal braces sticking out in resident areas.
Failure to implement and maintain effective annual training programs for multiple staff in abuse, resident rights, infection control, dementia care, and emergency preparedness.
Report Facts
Residents affected: 14
Temperature readings: 87.1
Weight: 187
Weight: 168.6
Weight: 167.4
Temperature: 45
Power outage start time: 1815
Power outage generator start time: 1906
Duration on temporary generator: 1598
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #112 | Social Services Director | Interviewed regarding Advanced Beneficiary Notice completion errors |
| Staff #110 | Administrator | Interviewed regarding ABN completion, emergency preparedness, and facility environment |
| Staff #33 | Assistant Maintenance Technician | Interviewed regarding power outage response and cooling system issues |
| Staff #32 | Maintenance Director | Interviewed regarding power outage, generator issues, and facility maintenance |
| Staff #69 | Registered Nurse | Interviewed regarding power outage response and resident safety |
| Staff #66 | Registered Dietician/Kitchen Manager | Interviewed regarding food storage temperatures and safety |
| Staff #59 | Director of Nursing | Interviewed regarding resident weights, staff training, and TB testing |
| Staff #73 | Accounting Clerk/Human Resources | Interviewed regarding TB testing and staff training compliance |
Inspection Report — Jul 17, 2024
Date: Jul 17, 2024
Visit Reason
On-site inspection of a Nursing Care Institution at Life Care Center of Tucson conducted 14-17 July 2024, classified as Other inspection type with Nursing Care Institution worksheet.
Findings
The inspection identified 18 deficiencies related to emergency preparedness, fire safety, electrical systems, and hazardous area protections. The facility failed to develop adequate emergency plans, maintain proper fire safety measures, and ensure functional emergency power systems.
Deficiencies (18)
Failure to develop a facility-based and community-based risk assessment prior to developing the emergency preparedness plan, posing potential risk to patients and staff during emergencies.
The emergency preparedness plan did not include the needs of the patient population or a delegation of authority as part of continuity of operations, risking disruption of services during emergencies.
Policies and procedures were not based on a current community and facility-based risk assessment; policies listed hazards not applicable to Arizona and did not match identified hazards.
Failed to maintain policies ensuring refrigerated foods were stored at or below 41 degrees; a power outage caused temperatures to reach 50 degrees, resulting in food disposal.
Lack of written policies and procedures for safe evacuation from the second floor, including care and treatment needs, staff responsibilities, and transportation.
Failed to develop a facility-based emergency preparedness training and testing program, risking untrained staff during emergencies.
Failed to provide training documentation showing new and existing staff reviewed emergency preparedness policies; staff were unfamiliar with the program and phone numbers.
Emergency and standby power systems were not functioning properly; the rental generator failed to start during a power outage, leaving the facility without power for over 30 minutes.
Failed to provide a safe means of egress from the soiled laundry room; exits were blocked by a laundry cart and a medication cart obstructed fire doors.
Failed to ensure proper rated fire doors protected hazardous areas; doors had holes, were removed, or propped open, compromising fire safety.
Failed to protect cooking equipment per NFPA 96 requirements; no approved hood system was installed in the therapy room and the cooking range was plugged in and functioning.
Failed to assure sprinkler system coverage in all parts of the facility; storage areas blocked sprinkler heads and the hydraulic design information sign was missing.
Failed to provide protective guards on light bulbs in several facility areas, risking accidental damage or fire.
Failed to conduct all required fire drills quarterly on each shift; missing drills during the first shift of Q1 2024 and third shift of Q2 2024.
Failed to ensure the emergency generator was permanently mounted; the rental generator failed to operate properly during a power outage causing loss of critical equipment function.
Emergency generator failed to transfer to emergency power within 10 seconds during a power outage, resulting in over 30 minutes without power.
Failed to ensure appliances were directly plugged into wall outlets rather than power strips, risking electrical overload and fire.
Allowed oxygen cylinders to be stored within five feet of combustibles, increasing fire risk to patients and staff.
Report Facts
Deficiencies cited: 18
Inspection Report — Jul 17, 2024
Annual Inspection
Date: Jul 17, 2024
Visit Reason
On-site complaint investigation of complaints AZ00212152, AZ00172805, AZ00172726, AZ00172400, AZ00172161, AZ00171759 and AZ00162971 combined with a compliance (annual) recertification survey at a Nursing Care Institution, conducted 14-17 July 2024.
Complaint Details
A recertification survey was conducted from July 14 through July 17, 2024 in conjunction with investigation of complaints AZ00212152, AZ00172805, AZ00172726, AZ00172400, AZ00172161, AZ00171759 and AZ00162971. The complaints involved issues including Advanced Beneficiary Notice accuracy and other resident care concerns.
Findings
This inspection found 20 deficiencies including failures in accurate completion of Advanced Beneficiary Notices for residents, inadequate temperature control during a power outage affecting 14 residents, incomplete annual staff training, missing fingerprint clearance cards and tuberculosis testing for staff, failure to weigh a resident as required, inadequate assistance with bathing for a resident, improper food storage temperatures, incomplete daily nurse staffing postings, and multiple environmental safety hazards such as peeling paint, sharp gouges, and protruding nails in resident areas.
Deficiencies (20)
§483.10(g)(17) — The facility failed to ensure two residents and/or their representatives received accurate and complete Advanced Beneficiary Notices when Medicare services terminated, including conflicting or missing selections on the forms.
§483.10(i) — The facility failed to provide adequate and comfortable temperature levels for 14 residents during a power outage, resulting in uncomfortably warm rooms without evidence of ambient temperature monitoring.
R9-10-406 — The facility failed to implement and maintain an effective annual training program for multiple staff members, including training on abuse, resident rights, infection control, dementia, and emergency preparedness.
R9-10-406 — The facility failed to ensure two staff members had fingerprint clearance cards as required for employment, risking resident safety.
R9-10-406 — The facility failed to ensure one staff member was free of tuberculosis prior to working in the facility, increasing risk of infection transmission.
§483.21(b)(3) — The facility failed to ensure initial and ongoing weights were conducted for one resident, risking unrecognized changes in condition.
§483.24(a)(2) — The facility failed to ensure one resident received assistance with bathing as scheduled, risking poor hygiene and skin infections.
R9-10-407 — The facility failed to ensure two residents and/or their representatives received accurate and complete Advanced Beneficiary Notices when Medicare services terminated, with conflicting or missing selections on the forms.
§483.35(g) — The facility failed to ensure the daily nurse staffing posting included all required information, notably omitting actual hours worked.
§483.60(i) — The facility failed to ensure multiple food items were stored at safe temperatures in the walk-in refrigerator, with temperatures exceeding safe limits, risking food-borne illness.
§483.80 — The facility failed to ensure one staff member was free of tuberculosis prior to working in the facility, risking resident infection.
§483.90(c) — The facility failed to ensure the emergency and standby power systems functioned properly during a power outage, resulting in loss of power to medical equipment, elevators, and refrigeration.
§483.90(i) — The facility failed to maintain a safe and comfortable environment, with multiple peeling paint areas, sharp gouges, protruding nails, and metal braces posing injury risks to residents.
§483.95 — The facility failed to maintain an effective annual training program for multiple staff, including emergency preparedness and dementia training, impacting resident safety and rights.
R9-10-412 — The facility failed to maintain accurate documentation of nursing personnel present and actual hours worked on daily staff postings.
R9-10-414 — The facility failed to ensure initial and ongoing weights were conducted for one resident as required by the care plan and facility policy.
R9-10-423 — The facility failed to store and maintain food at safe temperatures, risking foodborne illness due to walk-in refrigerator temperatures above recommended limits.
R9-10-425 — The facility failed to maintain a safe and comfortable environment, with multiple physical hazards such as peeling paint, sharp gouges, protruding nails, and metal braces posing injury risks.
R9-10-425 — The facility failed to maintain heating and cooling systems to keep the nursing care institution between 70°F and 84°F, resulting in uncomfortably warm rooms for 14 residents during a power outage.
R9-10-426 — The facility failed to ensure emergency and standby power systems were adequate and functional during a power outage, causing loss of power to critical systems and resident discomfort.
Report Facts
Deficiencies cited: 20
Complaints investigated: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #112 | Social Services Director | Interviewed regarding Advanced Beneficiary Notice completion errors |
| Staff #110 | Administrator | Interviewed regarding Advanced Beneficiary Notice completion and staff training deficiencies |
| Staff #33 | Assistant Maintenance Technician | Interviewed regarding power outage and temperature control issues |
| Staff #50 | Registered Nurse | Interviewed regarding facility condition and training deficiencies |
| Staff #59 | Director of Nursing | Interviewed regarding multiple deficiencies including training, staffing posting, and resident care |
| Staff #73 | Human Resources Accounting Clerk | Interviewed regarding staff training and fingerprint clearance card deficiencies |
| Staff #32 | Maintenance Director | Interviewed regarding power outage, facility condition, and food storage issues |
| Staff #66 | Registered Dietician | Interviewed regarding resident weight monitoring and food safety |
| Staff #95 | Central Supply Director/Staffing Coordinator | Responsible for daily staff posting preparation |
| Staff #40 | Cook/Kitchen Staff | Interviewed regarding food storage temperatures |
| Staff #9 | Certified Nursing Assistant | Mentioned in bathing assistance deficiency |
Inspection Report — Jun 14, 2024
Complaint Investigation
Date: Jun 14, 2024
Visit Reason
On-site complaint investigation of intakes AZ00211742 and AZ00195804 at a Nursing Care Institution, conducted 14 June 2024.
Complaint Details
An onsite complaint survey was conducted on June 14, 2024 for the investigation of intakes AZ00211742 and AZ00195804. Federal comments also note investigation of intakes AZ00211742 and AZ00195803 with no deficiencies cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Mar 5, 2024
Complaint Investigation
Date: Mar 5, 2024
Visit Reason
On-site complaint investigation of intakes AZ00206984 and AZ00207061 at a Nursing Care Institution, conducted 4-5 March 2024.
Complaint Details
An onsite complaint survey was conducted on March 4, 2024 through March 5, 2024 for the investigation of intakes #AZ00206984 and AZ00207061. There were no deficiencies cited.
Findings
No deficiencies were cited during this inspection.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 15, 2024
Complaint Investigation
Date: Feb 15, 2024
Visit Reason
On-site complaint investigation of intakes AZ00206227 and AZ00206228 at a Nursing Care Institution, conducted 15 February 2024.
Complaint Details
A complaint survey was conducted on February 15, 2024 for the investigation of intake #AZ00206227 and AZ00206228. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Feb 7, 2024
Complaint Investigation
Date: Feb 7, 2024
Visit Reason
On-site complaint investigation of complaints AZ00198851, AZ00201944, AZ00204240, AZ00205543, AZ00205876, AZ00172056, AZ199495, AZ00203334, AZ00204312, and AZ00205912 at a Nursing Care Institution, conducted 5 to 7 February 2024.
Complaint Details
The investigation of complaints AZ00198851, AZ00201944, AZ00204240, AZ00205543, AZ00205876, AZ00172056, AZ199495, AZ00203334, AZ00204312, AZ00205912 was conducted on February 5 and 7, 2024.
Findings
The inspection found two deficiencies related to neglect and abuse of resident #48, including failure to assist with toileting hygiene and inappropriate behavior by staff. Plans of correction were provided for both deficiencies.
Deficiencies (2)
§483.12 — The facility failed to ensure resident #48 was free from neglect when a CNA refused to change her brief, threw the brief at her, and demanded she change it herself despite her inability to stand. Multiple interviews confirmed the neglectful behavior and failure to provide required assistance.
R9-10-410 — The administrator failed to prevent neglect of resident #48 when staff refused to assist with toileting hygiene and threw a brief at the resident, forcing her to care for herself against her care plan. Interviews and policy review confirmed the neglect and abuse.
Report Facts
Deficiencies cited: 2
Complaints investigated: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #105 | Licensed Practical Nurse | Interviewed regarding neglect of resident #48 |
| Staff #16 | Director of Nursing | Interviewed regarding neglect of resident #48 |
| Staff #55 | Certified Nursing Assistant | Interviewed regarding refusal to assist residents |
| Staff #32 | Registered Nurse | Interviewed regarding refusal to assist residents |
| Staff #6 | Executive Director | Interviewed regarding staff responsibilities and neglect |
Inspection Report — Jan 19, 2024
Complaint Investigation
Date: Jan 19, 2024
Visit Reason
On-site complaint investigation of complaint AZ00204952 at a Nursing Care Institution, conducted 19 January 2024.
Complaint Details
The investigation of complaints (AZ00204952) was conducted on January 17, 2023, via closed record review, staff interviews, review of facility documentation and facility policy and procedures, and through the observation of current practice. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jan 5, 2024
Complaint Investigation
Date: Jan 5, 2024
Visit Reason
On-site complaint investigation of complaints AZ00204625 and AZ00204761 at a Nursing Care Institution, conducted 3 to 5 January 2024.
Complaint Details
The investigation of complaints AZ00204625 and AZ00204761 was conducted on January 3, 2024, resulting in eight deficiencies cited related to injury reporting, resident rights, neglect, and care planning.
Findings
The inspection found eight deficiencies related to failure to timely report an injury of unknown origin, failure to ensure a resident's representative could exercise rights, neglect of a resident with a hematoma, and failure to conduct neurological assessments. Plans of correction were provided for all deficiencies.
Deficiencies (8)
R9-10-403.F.2.a — The facility failed to ensure an injury of unknown origin was reported to the Administrator and state agency within 24 hours, resulting in delayed reporting of a facial bruise for Resident #4.
The facility failed to ensure that one resident's representative was able to exercise her rights regarding decisions about the resident's care, causing potential interference with healthcare decision-making for Resident #4.
§483.12 — The facility failed to ensure Resident #4 was free from neglect by staff, including failure to perform neurological assessments after identifying a hematoma.
§483.12(c) — The facility failed to report an injury of unknown origin to the Administrator and state agency within 24 hours, causing delayed communication and action regarding Resident #4's injury.
§483.21(b)(3) — The facility failed to assess Resident #4 according to professional standards, resulting in delayed clinically necessary treatment and lack of neurological assessment.
R9-10-410.B.3.b — The facility failed to ensure Resident #4 was free from neglect, including failure to conduct neurological assessments and delayed treatment after discovery of a hematoma.
R9-10-410.C.8 — The facility failed to ensure that Resident #4's representative could participate in treatment decisions, delaying appropriate care and hospital transfer.
R9-10-414.B.3.b — The facility failed to provide nursing care that assisted Resident #4 in maintaining the highest practicable well-being, including failure to perform neurological assessments after injury.
Report Facts
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #33 | Director of Nursing | Interviewed regarding delays in reporting and treatment related to Resident #4's injury and care. |
| Staff #91 | Licensed Practical Nurse | Interviewed about timing and actions related to Resident #4's hospital transfer and injury. |
| Staff #13 | Certified Nursing Assistant | Interviewed about observations of Resident #4's condition and bruising. |
| Staff #82 | Registered Nurse | Interviewed about notification of physician and neurological assessment for Resident #4. |
Inspection Report — Dec 7, 2023
Complaint Investigation
Date: Dec 7, 2023
Visit Reason
On-site complaint investigation of complaints AZ00209302 and AZ00203909 at a Nursing Care Institution, conducted 6-7 December 2023.
Complaint Details
The investigation of complaints AZ00209302 and AZ00203909 was conducted via record review, staff interviews, and observation. Evidence showed the facility failed to protect a resident from staff abuse, substantiating the allegations. Federal comments also referenced complaints AZ00203902 and AZ00203908 with similar findings.
Findings
The inspection substantiated that the facility failed to ensure a resident was free from physical abuse by staff. Two deficiencies were cited related to abuse and failure to protect the resident.
Deficiencies (2)
§483.12 — The facility failed to ensure that one resident (#10) was free from physical abuse by staff, including an incident where a CNA pushed the resident into a wall and yelled at her. The facility did not document the incident properly in the clinical record.
R9-10-410 — The administrator failed to ensure that a resident was not subjected to abuse by staff, as evidenced by the same incident involving CNA #50 pushing resident #10 and the lack of proper documentation and oversight.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #50 | Certified Nursing Assistant | Involved in physical abuse incident against resident #10. |
| Staff #16 | Certified Nursing Assistant | Witnessed the abuse incident involving staff #50 and resident #10. |
| Staff #1 | Certified Nursing Assistant | Provided interview regarding staff #50's performance and behavior. |
| Staff #80 | Director of Nursing | Reported abuse incident and confirmed timely reporting and suspension of staff #50. |
Inspection Report — Sep 15, 2023
Complaint Investigation
Date: Sep 15, 2023
Visit Reason
On-site complaint investigation of complaints AZ00200361 and AZ00200466 at a Nursing Care Institution, conducted 15 September 2023.
Complaint Details
The investigation of complaint AZ00200361, AZ00200466 was conducted on September 15, 2023. The investigation of complaint AZ00200359, AZ00200464 was conducted on September 15, 2023. There were no deficiencies found.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Aug 17, 2023
Complaint Investigation
Date: Aug 17, 2023
Visit Reason
On-site complaint investigation of intake AZ00198901 at a Nursing Care Institution, conducted 17 August 2023.
Complaint Details
A complaint survey was conducted on August 17, 2023 for the investigation of intake #AZ00198901. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Apr 20, 2023
Annual Inspection
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations related to providing adequate assistance with eating to residents, ensuring proper nutritional status and preventing weight loss.
Findings
The facility failed to ensure assistance with eating was provided for 2 out of 3 sampled residents, which could result in inadequate nutritional status and weight loss. Documentation showed multiple dates where assistance was not provided or documented, despite care plans indicating the need for assistance. Interviews with staff confirmed expectations for assistance and documentation, but gaps were found in practice.
Deficiencies (1)
Failure to provide assistance with eating for residents requiring help, leading to risk of inadequate nutrition and weight loss.
Report Facts
Weight: 193
Weight: 199.3
Weight: 197.2
Weight: 103.6
Weight: 98.4
Weight: 94.8
Weight loss percentage: 5.01
Weight loss percentage: 8.49
Weight loss: 5
Weight gain: 6
Weight loss: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) staff #99 | Interviewed about assistance with eating and documentation practices | |
| Licensed Practical Nurse (LPN) staff #62 | Interviewed about ensuring residents receive assistance with meals and reviewing CNA documentation | |
| Assistant Director of Nursing (ADON) staff #128 | Interviewed about care planning, restorative services, and expectations for feeding assistance and documentation |
Inspection Report — Apr 20, 2023
Routine
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding assistance with eating and nutritional care for residents, specifically focusing on whether residents received adequate help with eating to maintain their health.
Findings
The facility failed to ensure assistance with eating was provided for 2 out of 3 sampled residents, which could result in inadequate nutritional status and weight loss. Documentation showed multiple dates where assistance was not provided or documented, and interviews with staff revealed expectations for assistance and documentation were not consistently met.
Deficiencies (1)
Failure to provide assistance with eating for residents requiring help, leading to potential inadequate nutritional status and weight loss.
Report Facts
Weight: 193
Weight: 199.3
Weight: 197.2
Weight: 103.6
Weight: 98.4
Weight: 94.8
Weight loss percentage: 5.01
Weight loss percentage: 8.49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) staff #99 | Interviewed about assistance with eating and documentation | |
| Licensed Practical Nurse (LPN) staff #62 | Interviewed about ensuring residents receive assistance with meals and CNA documentation | |
| Assistant Director of Nursing (ADON) staff #128 | Interviewed about care planning, restorative services, and documentation expectations for feeding assistance |
Inspection Report — Mar 14, 2023
Routine
Date: Mar 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, environment, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare notices to residents, pervasive urine odor in resident areas, inadequate nail care for a resident, failure to follow physician orders for monitoring and treatment of congestive heart failure, improper catheter care leading to urinary tract infection risk, medication availability issues, medication administration errors exceeding 5%, and unsecured medication storage.
Deficiencies (8)
Failure to ensure residents and/or their representatives received the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when Medicare services terminated.
Failure to maintain an environment free of pervasive urine odors in resident areas.
Failure to provide nail care for a resident, resulting in poor grooming and personal hygiene.
Failure to ensure care and services were provided according to physician orders for a resident with congestive heart failure, including failure to notify provider of significant weight gain and edema.
Failure to provide appropriate catheter care for a resident, increasing risk of urinary tract infection.
Failure to ensure medication was obtained and available to meet the needs of a resident.
Medication error rate exceeded 5% due to incorrect dosing and administration of medications for two residents.
Failure to ensure medications were stored safely and secured in the medication cart, including leaving medications unsecured and computer screens open with resident information visible.
Report Facts
Sample size: 3
Medication error rate: 10.71
Medication administration opportunities: 21
Medication administration documented: 4
Weight gain: 14.8
Weight: 320.6
Weight: 298.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #93 | Social Services Director | Interviewed regarding failure to provide SNFABN to residents |
| Staff #57 | Business Office Manager | Interviewed regarding understanding of ABN and NOMNC processes |
| Staff #125 | Facility Administrator | Interviewed regarding expectations for ABN and NOMNC completion |
| Staff #67 | Certified Nursing Assistant (CNA) | Interviewed and observed regarding urine odor and catheter care |
| Staff #126 | Registered Nurse (RN) | Observed wound care and interviewed regarding nail care |
| Staff #127 | Nurse Practitioner (NP) | Observed wound care and interviewed regarding nail care |
| Staff #71 | Certified Nursing Assistant (CNA) | Interviewed regarding nail care procedures |
| Staff #80 | Registered Nurse (RN) | Interviewed regarding nail care procedures and documentation |
| Staff #4 | Director of Nursing (DON) | Interviewed regarding expectations for nail care, medication administration, catheter care, and medication availability |
| Staff #39 | Registered Nurse (RN) | Interviewed regarding weight monitoring and reporting for resident with CHF |
| Staff #47 | Certified Nursing Assistant (CNA) | Observed catheter care and interviewed regarding training |
| Staff #62 | Licensed Practical Nurse (LPN) | Interviewed regarding catheter care procedures |
| Staff #45 | Licensed Practical Nurse (LPN) | Observed medication administration and interviewed regarding medication availability and errors |
| Staff #41 | Licensed Practical Nurse (LPN) | Observed medication administration and interviewed regarding medication errors |
Inspection Report — Mar 8, 2022
Routine
Date: Mar 8, 2022
Visit Reason
Routine inspection of Life Care Center of Tucson to assess compliance with regulatory requirements including resident care, medication administration, infection control, staffing, and other areas.
Findings
The facility had multiple deficiencies including inconsistent advance directive documentation, incomplete and inaccurate Minimum Data Set (MDS) assessments, failure to complete PASRR screenings accurately, incomplete baseline and comprehensive care plans, inconsistent assistance with activities of daily living, inadequate wound care and monitoring, medication administration errors, insufficient staffing levels, cold food complaints, lapses in infection control during laundry processing and COVID-19 testing, and failure to educate residents on COVID-19 vaccination.
Deficiencies (19)
Inconsistent advance directive documentation for resident #185.
Incomplete and inaccurate Minimum Data Set (MDS) assessments for multiple residents (#45, #34, #4, #10, #30, #58).
Failure to complete and update PASRR screenings accurately for resident #10.
Baseline care plans missing key diagnoses and medication use for residents #45 and #130.
Care plan for resident #45 not revised to include wounds and pressure ulcers.
Resident #278 did not consistently receive assistance with activities of daily living due to staffing shortages.
Resident #387 surgical incision monitoring not consistently performed as ordered.
Resident #128 on hospice was not adequately supervised to prevent falls; fall mats were not consistently used.
Residents #42 and #45 did not consistently receive appropriate pressure ulcer care and prevention.
Residents #56, #11, and #4 with limited range of motion and mobility did not consistently receive restorative nursing services.
Resident #45 did not consistently receive bowel care as needed; prolonged intervals without documented bowel movements and no PRN medication administration documented.
Facility staffing levels were insufficient to meet resident needs; CNA and nursing hours were below required levels on multiple days; residents and staff reported delays in care and unmet needs.
Nurse staffing postings were inaccurate and did not reflect actual hours worked for RNs and LPNs on multiple days.
Resident #45 diagnosed with dementia received antipsychotic medication without adequate individualized care planning or documented non-drug interventions; monitoring and psychiatric assessment were lacking.
Medications for residents #45, #49, and #130 were administered outside of ordered parameters without proper documentation or physician notification.
Facility failed to ensure infection prevention protocols during laundry processing; staff wore contaminated PPE into clean areas and did not perform hand hygiene appropriately.
Facility failed to maintain infection control protocols during COVID-19 testing; staff did not perform hand hygiene, did not disinfect surfaces properly, and did not maintain social distancing.
Facility failed to educate and offer COVID-19 vaccination to residents #378, #381, #387, and #388 as required by policy.
Facility failed to provide food and drink at safe and appetizing temperatures; multiple residents complained of cold food and coffee; facility implemented plate warmers and other measures.
Report Facts
Deficiency count: 20
Deficiency count: 1
Staffing hours per patient day (HPPD): 3.81
Staffing days below CNA hours required: 18
Staffing days below RN and LPN combined hours required: 16
Staffing days below total direct care nursing hours required: 17
Medication administration outside parameters: 20
Medication administration outside parameters: 10
Medication administration outside parameters: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #14 | Director of Nursing | Named in multiple interviews related to deficiencies and expectations |
| Staff #60 | Infection Preventionist | Named in interview and observations related to COVID-19 testing deficiencies |
| Staff #91 | Staffing Coordinator | Named in interview related to staffing and nurse posting deficiencies |
| Staff #42 | Laundry & Housekeeping Supervisor | Named in interview related to laundry infection control deficiencies |
| Staff #136 | Dietician | Named in interview related to food temperature complaints |
| Staff #133 | District Pharmacy Clinical Manager | Named in interview related to psychotropic medication use |
Report
10 CMS Surveys
CMS Survey — Apr 20, 2023
Apr 20, 2023
CMS Survey — Dec 7, 2023
Dec 7, 2023
CMS Survey — Jan 5, 2024
Jan 5, 2024
CMS Survey — Feb 7, 2024
Feb 7, 2024
CMS Survey — Jul 17, 2024
Jul 17, 2024
CMS Survey — Aug 15, 2025
Aug 15, 2025
CMS Survey — Sep 18, 2025
Sep 18, 2025
CMS Survey — Mar 8, 2022
Mar 8, 2022
CMS Survey — Mar 14, 2023
Mar 14, 2023
CMS Survey — Jul 17, 2024
Jul 17, 2024
Viewing
Loading inspection reports...
