Life Care Center of Tucson: Elopement Risk Failure - AZ
The resident, identified in inspection records as Resident 119, has limited communication ability and frequently wandered into other residents' rooms, prompting staff to start 15-minute monitoring checks. On August 28, 2025, following a significant change in his condition, he was formally reassessed and designated high risk. His care plan was updated to reflect that.
Five days later, on September 2, a second assessment overrode the first. The high-risk designation was removed. The change was never reflected in the conference care plan.
He left the facility on a weekend, dressed, and walked out the front door. The receptionist, whose shift runs from 8:00 AM to 4:30 PM, reportedly opened the door for him. The exit happened after 4 PM.
There are no wander guards at Life Care Center of Tucson. There are no security cameras.
The Director of Nursing acknowledged to inspectors on September 17, 2025, that the facility did not adequately protect the resident after his elopement risk was identified. The facility does maintain an elopement protocol: a yellow binder with photos of residents on elopement watch, kept at nurse stations and the front desk, along with a 15-minute check policy. A CNA who had been present at the resident's admission told inspectors she believed wander guards could have prevented the incident.
The facility's own elopement policy, last revised in November 2024, states that each resident receives adequate supervision and assistance devices to prevent accidents.
Resident 119 understood conversations, his caregivers said, but could not easily communicate. He wandered. Staff knew it. For five days in late August, his chart said so officially. Then it didn't, and on a weekend afternoon, with the shift changing and no camera watching the door, he walked out.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Tucson from 2025-09-18 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
LIFE CARE CENTER OF TUCSON in TUCSON, AZ was cited for violations during a health inspection on September 18, 2025.
On August 28, 2025, following a significant change in his condition, he was formally reassessed and designated high risk.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.