Inspection Reports for
Life Care Center of Tucson

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.

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.

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.

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.

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.

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.

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, and staff did not clearly document the specific care tasks performed.

The complaint investigation was substantiated based on resident and staff interviews, clinical record review, and facility policy review. The CNA was found to have refused care and neglected the resident, constituting abuse and neglect.

The investigation found that the facility failed to ensure resident care was not neglected, with evidence that a CNA refused to assist a resident with toileting needs, threw a brief at the resident, and neglected care requests. Interviews with residents, staff, and the Director of Nursing confirmed the neglect and abuse.

The complaint investigation was substantiated with findings that the facility delayed hospital transfer after a hematoma was discovered on resident #4, failed to perform neurological assessments, delayed reporting the injury to the state agency, and did not allow the resident's representative to exercise rights regarding care decisions.

The facility failed to ensure that the resident's representative could exercise rights regarding care decisions, delayed sending the resident to the hospital after a hematoma was discovered, failed to perform timely neurological assessments, and did not report the injury of unknown origin to the state agency within 24 hours. These deficiencies posed minimal harm or potential for actual harm to a few residents.

The complaint was substantiated based on clinical record reviews, facility documentation, resident and staff interviews, and policy review. The incident involved CNA #50 pushing resident #10 into a wall and yelling at her, witnessed by another CNA (#16). The CNA was suspended immediately and the incident was reported timely per state guidelines.

The facility failed to ensure that resident #10 was free from physical abuse by staff, specifically an incident where a CNA pushed the resident into a wall and yelled at her. The CNA was suspended immediately following the incident, and the facility's abuse protection policy was reviewed.

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.

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.

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.

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.