Below 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 Life Care Center Of Tucson during CMS and state inspections, most recent first.
A resident with multiple comorbidities, intact cognition, and a care plan requiring two-person assistance for toileting repeatedly requested help for a brief change using the call light and by wheeling to the nurses’ station. A CNA, who had documented training on professional language and abuse prevention, allegedly failed to respond to the call light, refused to assist because a second staff member was not available, and used profanity toward the resident in the context of the resident’s complaints about delayed care, causing the resident to cry and feel unsafe. Another staff member reported seeing the CNA on her phone while call lights were on, hearing the profane statement directed at the resident, and later comforting the resident, while additional staff confirmed the resident’s report that the CNA was rude and blamed her for not receiving care. The facility’s abuse policy defined mental and verbal abuse to include profane, insulting, or degrading language and depriving a resident of care, which aligned with the described interaction.
Two residents with dementia and severe cognitive impairment, one already care planned for risk of behavioral changes and physical aggression, were seated in a hallway with other residents when an altercation occurred. One resident was heard yelling and striking the other across the chest with a stuffed animal, and the other resident responded by kicking the aggressor in the leg. An ADON heard screaming, directly observed the physical contact between the residents, and later stated she considered the incident to be abuse. Skin assessments showed no injuries, but the event demonstrated that the facility did not effectively protect a resident’s right to be free from abuse by another resident, despite an abuse‑prevention policy requiring identification, assessment, and care planning for residents with verbally or physically aggressive behaviors.
A resident with moderate cognitive impairment and multiple medical conditions was not initially identified as an elopement risk, despite wandering behaviors. After reassessment, the resident was placed on 15-minute checks and listed in the Elopement book, but inconsistencies in risk assessment and care plan updates occurred. The resident was able to exit the facility unsupervised through the front door, with no Wander Guards or security cameras in place, and staff acknowledged that adequate protection was not provided.
A resident with chronic pain was prescribed Dilaudid, but an LPN repeatedly logged out doses on the narcotic count sheet without documenting administration on the MAR. This discrepancy led to the resident experiencing pain and raised concerns about possible medication diversion, as confirmed by staff interviews and facility policy review.
A power outage led to a malfunctioning generator and cooling system, causing uncomfortably high temperatures in a LTC facility. Several residents, including those with chronic conditions, reported discomfort due to the heat. Staff interviews revealed a lack of systematic temperature monitoring and inadequate emergency protocols, contributing to the prolonged discomfort.
The facility failed to maintain safe food storage temperatures in the walk-in refrigerator, with temperatures recorded above the critical limit of 40F. Despite policy requirements, actual temperatures were higher than recorded, posing a risk for food-borne illnesses. Staff interviews revealed the refrigerator was used for storing various food items, and maintenance errors contributed to the issue.
The facility experienced a complete power outage due to a failure in the temporary generator, which had been in use since 2020. This outage affected medical equipment, elevators, and refrigeration units, and required manual intervention to restore power. Residents on oxygen concentrators were switched to O2 tanks, and staff faced challenges due to non-functional elevators and a lack of standard procedures for power outages. The deficiency was confirmed during an exit conference.
The facility failed to maintain a safe and comfortable environment, with observations revealing safety hazards such as peeling paint, sharp handrails, and protruding nails. Staff interviews indicated a lack of proactive maintenance and communication, with issues often going unreported. The Administrator stressed the importance of a safe environment, but the facility's work order report showed no records of the identified issues, highlighting a gap in maintenance practices.
The facility failed to maintain an effective training program, resulting in incomplete or missing documentation for required annual training in areas such as abuse, resident rights, infection control, dementia care, and emergency preparedness for several staff members, including RNs, LPNs, CNAs, the DON, and the Administrator. Interviews confirmed the training program was not effectively managed, despite having a policy in place.
A resident with multiple health issues, including anxiety and malnutrition, did not consistently receive scheduled bathing assistance, as documented in the facility's records from April to July 2024. The Director of Nursing acknowledged that the facility's documentation did not clearly indicate whether bathing tasks were completed, and staff were not consistently reporting or documenting refusals. This failure could lead to poor hygiene and skin infections.
The facility failed to provide accurate Advanced Beneficiary Notices (ABNs) to two residents when Medicare services ended. One resident received a form with conflicting options selected, while another's form had no options selected, leading to ambiguity about their service continuation choices. Staff interviews confirmed the errors, with the Social Services Director taking responsibility.
A resident admitted with multiple health conditions was not weighed upon admission as required by facility policy, leading to a deficiency in monitoring their condition. The weight recorded was taken from hospital transfer records instead of being measured by facility staff. The facility policy mandates weighing residents within 24 hours of admission and regularly thereafter, which was not followed, potentially affecting the resident's health.
The facility did not ensure the daily staff posting was current and accurate, as required by policy. On a specific day, the posting displayed outdated information, including an incorrect census and missing actual hours worked by staff. The DON acknowledged the issue, noting that the staffing coordinator prepares postings, and the weekend receptionist is responsible for updating them.
The facility failed to ensure that the Administrator was free of TB before starting work. Despite being hired in early 2024, the Administrator did not provide a TB test result until July, contrary to facility policy requiring a negative TB test before employment. The Administrator, who walks the facility floors and may contact residents, was only tested after the deficiency was identified.
Verbal Abuse and Failure to Respond to Resident’s Request for Incontinence Care
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse by a CNA. The resident, who had type 2 diabetes mellitus with foot ulcers, absence of the left foot, morbid obesity, and a mood disorder, was care planned for ADL self-care deficits and required maximum assistance for toileting and two-person dependent assistance with transfers. A quarterly MDS showed the resident had a BIMS score of 14, indicating intact cognition, and required substantial assistance for toilet transfers. On the morning in question, an event note documented that the resident was wheeling herself in her wheelchair in the hallway to the nurses’ station to request assistance with a brief change when a CNA seated at the nurses’ station heard her, turned around, and made an inappropriate comment, after which the resident began crying. The facility’s investigation materials described differing accounts of the interaction but consistently referenced the use of profanity by the CNA in the context of the resident’s request for care. The resident reported that she had not received care that morning, had urinated on herself, and had activated her call light, but the CNA would not answer it. The resident stated that when she told the CNA she was going to notify someone about the lack of assistance, the CNA became angry, stood up, and told her, “it’s your fucking fault,” which made her cry and feel unsafe. A staff member (Staff #118) provided a written statement and interview indicating that around 5:15 a.m. he observed multiple call lights on, including the resident’s, and saw the CNA sitting at the nurses’ station on her phone. He stated that the resident came out of her room begging for help with a brief change, that the CNA refused because she did not have a second person to assist, and that at one point the CNA told the resident, “it was [the] resident’s fucking fault,” after which the resident went back to her room crying. The CNA involved had documented training on professional language and on abuse, neglect, exploitation, resident rights, respect in the workplace, and prevention of abuse, including mental and verbal abuse. Her written statement acknowledged that the resident’s call light had been on since about 4:00 a.m. and that the resident later came out of her room angry about the wait; she claimed she agreed with the resident and went downstairs to get another CNA, and admitted she may have used the term “fuck” but denied directing it at the resident. Another CNA (Staff #24) stated that the resident was on “cares in pairs” because she accused staff of not helping her, that the resident used her call light frequently and wanted care immediately, and that delays could occur due to the need for two staff, though communication about delays could ease the situation. A staff member (Staff #38) reported that the resident later said she had a rough morning because she needed help and the CNA was rude and blamed her for not getting care due to the “cares in pairs.” The facility’s abuse policy defined mental and verbal abuse as conduct, including the use of profanity, that can cause humiliation, intimidation, fear, shame, agitation, or degradation, and included mocking, insulting, ridiculing, and threatening residents, including depriving a resident of care, as examples of mental and verbal abuse. The facility’s documentation also showed that the CNA had signed an education acknowledgment form stating she was trained to use professional language and that profanity was prohibited at work. The investigation report and staff interviews consistently placed the resident in a position of repeatedly requesting assistance for incontinence care, with her call light on and her coming into the hallway to seek help, while the CNA did not provide the requested care and used or was alleged to have used profanity in response to the resident’s complaints. The DON acknowledged receiving a report that the CNA was not helping the resident and had sworn at her, and stated that verbal abuse of residents can affect a resident’s psychological well-being. The combination of the resident’s report, corroborating staff statements, and the facility’s own policy definitions formed the basis for the finding that the resident was not kept free from verbal abuse.
Failure to Prevent Resident-to-Resident Physical Abuse in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident. One resident with dementia and severe cognitive impairment, who had no documented history of verbal or physical behaviors toward others, was care planned for impaired cognitive ability with interventions such as cueing, orienting, and supervision as needed. Another resident, also with dementia and severe cognitive impairment, had a care plan identifying risk for behavioral changes related to dementia and a separate care plan identifying risk for physical aggression during ADL care and showers, including monitoring for behaviors in the dining area and for touching/striking other residents or staff. On the date of the incident, both residents were seated in a hallway surrounded by other residents when an altercation occurred. An event progress note documented that one resident was heard yelling at another, while the other resident was also yelling and hitting the first resident across the chest with a stuffed animal. The note further documented that the first resident then kicked the second resident in the leg. A similar event note for the second resident described the same sequence of events from that resident’s perspective. Skin assessments completed for both residents on the same day showed intact skin with no redness or bruising. The Assistant DON reported hearing screaming outside her office and then witnessing one resident hitting the other across the chest with a stuffed animal and the other resident kicking back. She stated that she was the only staff member to witness the incident and that she would consider the incident to be abuse. The facility’s 5‑day investigation report verified the allegation based on the evidence collected and noted that both residents were unable to recall the incident. The facility’s abuse‑prevention policy stated that procedures include identification, assessment, and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict, including verbally and physically aggressive behaviors. Despite this, the altercation occurred between the two residents, constituting a failure to protect one resident’s right to be free from abuse by another resident.
Failure to Prevent Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for a resident with multiple medical conditions, including moderate cognitive impairment. Upon admission, the resident was not initially assessed as being at risk for elopement, despite having a BIMS score of 4 and exhibiting wandering behavior. The resident was later identified as at risk for elopement after a reassessment, and interventions such as inclusion in the Elopement book and 15-minute checks were implemented. However, there was inconsistency in the risk assessments and care plan updates, as a subsequent assessment overrode the high-risk status without proper reflection in the care plan. The resident was able to exit the facility through the front door after 4 PM, reportedly with the assistance of the receptionist, despite being on 15-minute checks and listed in the Elopement book. At the time, two facility entrances were locked after 4 PM, while the others required a security code, but there were no Wander Guards or security cameras in place. Staff interviews revealed that monitoring relied primarily on 15-minute checks and staff awareness, with no electronic monitoring devices used for residents at risk of elopement. The facility's policy required the environment to remain as free of accident hazards as possible and for residents to receive adequate supervision and assistive devices to prevent accidents. Despite these policies, the resident was able to leave the facility unsupervised, and staff acknowledged that adequate protection was not provided after the resident's elopement risk was identified.
Failure to Administer and Document Pain Medication per Physician Orders
Penalty
Summary
A resident with dementia, cervical spine fusion, and a right humerus fracture was admitted to the facility and placed on pain medication therapy for chronic pain syndrome. The care plan required administration of analgesic medications as ordered by the physician and monitoring for side effects and effectiveness. A physician's order specified Dilaudid (Hydro-morphine HCI) 2 mg oral tablets, with 0.5 mg to be given every 4 hours as needed for pain. Review of the narcotic count sheet showed that an LPN logged out doses on multiple occasions, but the Medication Administration Record (MAR) did not reflect administration of the medication on several dates when the narcotic count sheet indicated it had been dispensed. Further review revealed that the resident complained of pain, and the nurse on duty was unable to administer pain medication due to discrepancies in the narcotic count sheet and medication cart key handoff times. Staff interviews indicated that the LPN may have either failed to document administration on the MAR or possibly diverted the medication, as it was not reasonable for documentation to occur on the narcotic count sheet but not on the MAR multiple times in a short period. Facility policy required medications to be administered and documented per physician orders, and defined misappropriation to include missing or diverted prescription medications.
Failure to Maintain Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain adequate and comfortable temperature levels for 14 residents, resulting in an environment that was not homelike or comfortable. On the morning of July 15, 2024, surveyors noted a significant temperature difference upon entering the facility, which felt uncomfortably warm. Interviews with staff revealed that a power outage the previous evening had caused the generator to malfunction, preventing the cooling system from activating. This led to elevated temperatures in residents' rooms, with some rooms registering temperatures as high as 87.1 degrees Fahrenheit. Several residents, including those with conditions such as dementia, chronic obstructive pulmonary disease, and heart failure, reported discomfort due to the heat. Observations confirmed that air conditioning units in many rooms were either not functioning or blowing only room temperature air. Residents expressed their discomfort, with some stating they were unable to sleep well due to the heat. Staff interviews indicated that there was no systematic approach to monitoring room temperatures or relocating residents to cooler areas during the outage. The maintenance staff acknowledged the issues with the generator and cooling system, noting that the chiller took several hours to cool the facility. Despite weekly tests on the generator, there was no alarm system to alert staff of malfunctions. The facility lacked a clear protocol for managing such situations, and staff were not adequately trained in emergency procedures, such as evacuating non-ambulatory residents from the second floor. The absence of a documented plan for addressing temperature control during power outages contributed to the prolonged discomfort experienced by the residents.
Improper Food Storage Temperatures in Walk-In Refrigerator
Penalty
Summary
The facility failed to ensure that multiple food items were stored at safe temperatures in accordance with professional standards, potentially placing residents at risk for food-borne illnesses. During observations of the kitchen's walk-in refrigerator, temperatures were consistently recorded above the critical limit of 40 degrees Fahrenheit, with readings of 45F, 42F, and 50F on different occasions. Despite the facility's policy requiring temperatures to be under 40F, the temperature logs inaccurately recorded temperatures within the acceptable range, suggesting a discrepancy between actual and recorded temperatures. Interviews with kitchen staff and the Registered Dietician revealed that the walk-in refrigerator was used to store various food items, including dairy, meat, and leftovers, all of which require safe storage temperatures to prevent bacterial growth. The Maintenance Director admitted that the refrigerator was mistakenly set to 40F during maintenance, and the external thermometer was broken, leading to incorrect temperature readings. The Executive Director acknowledged the issue and stated that corrective measures were being implemented. The facility's policy emphasized the importance of maintaining food storage temperatures to prevent foodborne illnesses, highlighting the deficiency in adhering to these standards.
Emergency Power System Failure
Penalty
Summary
The facility failed to ensure that its emergency and standby power systems were functioning properly, which led to a complete power outage on July 14, 2024. The facility had been relying on a rental generator since March 2, 2020, and during the power failure, the temporary generator did not activate, leaving the facility without power. This outage affected critical systems, including medical equipment, elevators, and refrigeration units. Staff interviews revealed that the maintenance director was notified of the outage and arrived at the facility to find it in darkness, with staff panicking. It took approximately one hour to troubleshoot and manually start the generator, but the chillers remained inactive due to high voltage requirements. Additionally, the circular pumps were bypassed, and alarms were turned off, which contributed to the delay in addressing the issue. The power outage had significant implications for resident care, as those on oxygen concentrators had to be switched to O2 tanks. The lack of power also raised concerns about resident safety, as the elevators were non-functional, preventing the movement of residents if necessary. Staff interviews indicated a lack of standard procedures for handling power outages, and no mock disaster drills had been conducted. The absence of red plugs in resident rooms further complicated the situation, as extension cords had to be used. The deficiency was confirmed during the exit conference on July 18, 2024, highlighting the facility's prolonged reliance on a temporary generator without a permanent solution in place.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for residents, as observed during a walk-through on July 14, 2024. Several safety hazards were identified, including missing doorway frames with peeling paint, rough and sharp handrails, and doorframes with gouges. Additionally, a nail was found sticking out at the nurse's station, and screws were protruding from a handrail by the stairway. These conditions posed potential risks for injury to residents and staff. Interviews with staff revealed a lack of proactive maintenance and communication regarding the facility's condition. A Registered Nurse noted that maintenance had not sought input from staff or residents about necessary repairs, and the overall appearance of the facility was accepted as it was. The Maintenance Director acknowledged that while priority work orders related to resident safety were addressed promptly, other issues like painting took longer to resolve. The Director also mentioned that maintenance walk-throughs were conducted weekly, but issues not reported by staff or residents might go unnoticed. The Administrator emphasized the importance of maintaining a clean and safe environment to ensure residents' quality of life. However, a review of the facility's work order report showed no records of the identified issues, indicating a gap in the reporting and addressing of maintenance needs. The facility's policies on preventive maintenance and resident rights highlighted the requirement for a safe and homelike environment, which was not upheld in this instance.
Deficient Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, as evidenced by the lack of completion of required annual training in key areas such as abuse, resident rights, infection control, dementia care, and emergency preparedness. Employee records revealed that several staff members, including registered nurses, licensed practical nurses, certified nursing assistants, the Director of Nursing, the Maintenance Director, and the Administrator, had incomplete or missing documentation for these mandatory trainings. For instance, some staff members had not completed emergency preparedness training, while others lacked documentation for abuse or infection control training. Interviews with facility staff, including the human resources accounting clerk and the Director of Nursing, confirmed that the training program was not effectively managed. The human resources accounting clerk indicated that training notifications were typically sent via email from the corporate office, and all staff were required to complete the training annually based on their hire date. However, the Director of Nursing acknowledged that not all staff had completed the necessary training, despite having a policy in place that outlined the annual training requirements. The facility's policy on yearly required training did not include dementia care, further contributing to the deficiency.
Failure to Assist Resident with Bathing
Penalty
Summary
The facility failed to ensure that a resident received assistance with bathing, which could result in poor hygiene and skin infections. The resident, who was admitted with diagnoses including anxiety, depression, malnutrition, and a history of venous thrombosis, had a care plan indicating a need for assistance with bathing due to weakness and decreased mobility. Despite being scheduled for baths twice a week, the resident's shower/bathing task sheets from April to July 2024 showed multiple instances where bathing did not occur, and refusals were not consistently documented. Interviews with the Director of Nursing revealed that the facility's skin care alert form was being used to document various tasks, but it did not specify whether a shower, hair washing, or nail care was completed. The DON acknowledged that staff were not identifying which specific task was being done and emphasized the expectation that CNAs should report refusals to the nurse, who should then document the refusal and have the resident sign it. The facility's policy stated that residents would receive assistance as needed for ADLs, and any changes in ability should be reported to the nurse.
Inaccurate Completion of Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide accurate and complete Advanced Beneficiary Notices (ABNs) to two residents when their Medicare services were terminated. Resident #222, who was admitted with multiple diagnoses including severe cognitive impairment, received an ABN that incorrectly had both option 1 and option 3 selected, which are conflicting choices. This error in the form could lead to confusion about the resident's decision regarding the continuation of services and their financial liability. Resident #223, who was cognitively intact, received an ABN form where no options were selected, leaving ambiguity about the resident's choice to continue or discontinue services. Interviews with staff revealed that the Social Services Director acknowledged the errors in completing the ABNs and took responsibility for the inaccuracies. The administrator confirmed that the ABNs were not completed accurately, which could impact reimbursement and resident rights.
Failure to Conduct Initial and Ongoing Weights for Resident
Penalty
Summary
The facility failed to ensure that initial and ongoing weights were conducted for a resident, leading to a deficiency in monitoring the resident's condition. The resident, who was admitted with diagnoses including anoxic brain damage, Parkinson's disease, and chronic respiratory disease, was not weighed upon admission as required by the facility's policy. Instead, the weight recorded in the clinical record was taken from the hospital transfer records. This oversight was confirmed during an interview with a Registered Dietician, who stated that the resident should have been weighed monthly to assess and monitor weight loss, fluctuations, and fluid shifts. The Director of Nursing confirmed that the facility policy mandates all residents be weighed within 24 hours of admission, weekly for the first four weeks, and then monthly. The failure to weigh the resident as per policy could result in significant weight changes going unrecognized, potentially affecting the resident's health. The facility's policy and procedures emphasize the importance of accurate weight measurement for various clinical assessments and interventions, highlighting the deficiency in adhering to these standards.
Failure to Update Daily Staff Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting included the correct and up-to-date information as required by their policy. On July 14, 2024, the daily staff posting was observed to be outdated, displaying information from July 12, 2024, with a census of 60, while the actual census on July 14, 2024, was 58. Additionally, the posting did not include the actual hours worked by staff, which is a requirement according to the facility's policy. The Director of Nursing (DON) acknowledged the outdated posting and indicated that the Central Supply Director/staffing coordinator is responsible for preparing the postings, with the weekend receptionist tasked with updating them. The facility's policy, revised on December 13, 2023, mandates that nurse staffing information be posted daily in a prominent location, accessible to residents and visitors, and must include the facility name, current date, resident census, and total number of staff and actual hours worked per shift. The policy also requires that any staff absences due to callouts or illness be reflected in the posting. The failure to update the staff posting as per the policy resulted in incorrect information being displayed, which was not in compliance with the facility's procedures.
Failure to Ensure TB Testing for Administrator
Penalty
Summary
The facility failed to ensure that a staff member, specifically the Administrator, was free of tuberculosis (TB) prior to commencing work. The Administrator was hired on January 8, 2024, but did not provide a current TB test result before starting her duties. This oversight was confirmed during an interview with the accounting clerk/human resources personnel, who acknowledged that the Executive Director is supposed to have a TB test before working in the building to prevent the risk of TB spreading. Further interviews revealed that the Administrator herself admitted to not having a TB test prior to working at the facility, although she was tested on July 16, 2024, with results pending. The Director of Nursing confirmed that all new hires are required to show a negative TB test result before working. Despite not interacting directly with residents, the Administrator walks the floors and can come into contact with residents, increasing the risk of TB exposure. The facility's policy, revised in June 2024, mandates TB testing in accordance with CDC guidelines, which was not adhered to in this case.
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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) |
|---|---|---|---|---|
| Casas Adobes Post Acute Rehab Center | 0.6 mi | ★★★★★ | 3 | 0 |
| La Canada Care Center | 2.2 mi | ★★★★★ | 7 | 0 |
| Mountain View Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Brookdale Santa Catalina | 5 mi | ★★★★★ | 4 | 0 |
| Catalina Post Acute And Rehabilitation | 5.7 mi | ★★★★★ | 12 | 0 |
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