Life Care Center Of Tucson
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
elopement incident through messages, but she was not on duty that weekend. Of the four facility entrances, two are locked after 4 PM, and the others require a security code to exit.An interview was conducted with
the CNA # 22 on September 17, 2025, at 4:41 PM revealed that the staff monitor residents assessed for elopement risk using a yellow binder and conduct 15-minute checks for those listed. The CNA # 22 further stated that she was present when the resident was admitted and stated that the resident # 119 understands conversations but has limited communication ability. He frequently walked around his room and occasionally entered others' rooms, requiring redirection-prompting the start of 15-minute checks.
Initially, he wasn't considered at risk, but his status changed after a week following reassessment. I was informed that he exited the facility through the front door one weekend after 4 PM, reportedly assisted by
the receptionist. I believe wander guards could help prevent such incidents.An interview was conducted with the Director of Nursing (DON / Staff # 100) on September 17, 2025, at 6:12 PM. It was revealed that Residents are assessed for elopement risk upon admission, and staff monitor for wandering during daily rounds. The Elopement Book, containing resident photos and demographics, is kept at all nurse stations and the front desk. The receptionist, on duty from 8:00 AM to 4:30 PM, monitors the front door. According to
the AD's interview, the recent incident involved a resident exiting through the front door. Initially, the resident was not at risk, but following a significant condition change on August 28, 2025, an assessment identified him as high risk, and the care plan was updated. However, a subsequent assessment on September 2, 2025, overrode this update, and the change was not reflected in the conference care plan. The facility maintains a yellow binder for residents on elopement watch, along with a 15-minute check protocol. Staff #100 stated to remember the resident from his admission and stated the resident could understand but had limited communication and often wandered into other rooms, prompting redirection and 15-minute checks.
Staff #100 stated the resident was later reassessed as a risk. Staff #100 stated that the resident left the faciity on a weekend, dressed and exited through the front door, reportedly opened by the receptionist after 4 PM. There are no Wander Guards or security cameras in place. Staff #100 acknowledged that the facility did not adequately protect the resident after his elopement risk was identified.A review of the facility policy titled Elopement, last revised on November 19, 2024, revealed that the resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents.
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LIFE CARE CENTER OF TUCSON in TUCSON, AZ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TUCSON, AZ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LIFE CARE CENTER OF TUCSON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.