Arizona State Veteran Home-Tucson
555 East Ajo Way, Tucson, AZ 85713 · Government - State · 120 certified beds · (520) 638-2150 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2025
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.9% | 10.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.7% | 5.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.2% | 1.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 3.9% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.1% | 2.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 19.6% | 12.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 6.2% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.6% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 14.3% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.8% | 10.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 87.3% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.00 | 1.47 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.07 | 1.42 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 116.9 residents a day — about 97% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.09 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.63 hrs/resident/day on weekends vs 5.22 on weekdays — 11% thinner on weekends. RN hours go from 0.77 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · F2026-04-10 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, facility documentation, and policy review, the facility failed to ensure that staffing information (Payroll-Based Journal, PBJ) submitted to the Centers for Medicare and Medicaid Services (CMS) was accurate and submitted in a timely manner. The universe was 23. This deficient practice could have resulted in residents receiving inadequate care due to a potential lack of staffing. Findings included:The PBJ Staffing Data Report for Fiscal Year (FY) Quarter 1, 2026 (October 1-December 31), revealed that the facility failed to submit data for the quarter. A request made during the entrance meeting on April 7, 2026 at 8:38 a.m. for the PBJ staff data for the Quarter 1 FY 2026. The facility provided the data submitted to CMS, which was received by the survey team on April 10, 2026, at 10:00 a.m.An interview was conducted with the Business Office Manager (Staff #64) on April 10, 2026, at 9:48 a.m. Staff #64 stated that she was the qualified personnel responsible for processing and submitting this data. Staff #64 stated that the PBJ staffing data had been submitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-10 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to coordinate/implement PASRR findings by failing to ensure one resident (#8) out of three residents sampled was appropriately screened and referred for a Level II PASSR (Pre-admission Screening and Record Review) evaluation upon identification of a serious mental illness, in accordance with PASSR requirements. The universe was 23. The deficient practice has the potential to result in failure to identify and provide necessary specialized services.Findings include:Resident #8 was admitted to the facility on [DATE] with diagnoses of major depressive disorder; insomnia, post-traumatic stress disorder (PTSD), chronic; and psychotic disorder with hallucinations due to a known physiological condition.An admission PASRR, dated March 10, 2025, indicated that Resident #8 had a Serious Mental Illness (SMI) diagnosis of major depression. It also indicated he had a substance related disorder as well. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-10 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure one resident (#8) out of three residents sampled was appropriately screened and referred for a Level II PASSR (Pre-admission Screening and Record Review) evaluation upon identification of a serious mental illness, in accordance with PASSR requirements. The universe was 23. The deficient practice has the potential to result in failure to identify and provide necessary specialized services.Findings include:Resident #8 was admitted to the facility on [DATE] with diagnoses of major depressive disorder; insomnia, post-traumatic stress disorder (PTSD), chronic; and psychotic disorder with hallucinations due to a known physiological condition.An admission PASRR, dated March 10, 2025, indicated that Resident #8 had a Serious Mental Illness (SMI) diagnosis of major depression. It also indicated he had a substance related disorder as well. The PASSR noted that the most recent substance use was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-29 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure one resident (#1) was free from verbal abuse from visitors. The deficient practice could lead to physical and psychosocial harm to residents.Findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care, pneumonia, and urinary tract infection (UTI).Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated that a Brief Interview for Mental Status (BIMS) was not able to be completed. However, staff assessed Resident #1's cognitive skills for daily decision making to be severely impaired. The same MDS did not indicate Resident #1 exhibited behaviors of any type.Review of the clinical record revealed Progress Note dated May 23, 2023 at 3:03 P.M. that indicated Resident #1 had a caregiver at bedside. The note further indicated that a CNA (Certified Nursing Assistant) reported the resident had bitten the caregiver…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-29 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and review of the facility's policies and procedures, the facility failed to protect rights of one resident (resident #10) to be free from misappropriation from staff. The deficient practice could result in further incidents of staff to resident financial abuse. Findings include: -Resident #10 was admitted to the facility on [DATE], with diagnoses that include Bradycardia, atrial fibrillation, bipolar disorder, anxiety, dementia, and peripheral vascular disease. Review of the Significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A review of the SA(state agency) complaint system revealed that on June 18, 2024 at 10:00 a.m. an incident was reported by the facility that resident #10 had reported to her nurse, she had been asked for money by a previous employee (staff #75) that had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-11-13 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility policy and procedure, the facility failed to ensure three of three sampled ice machines were cleaned and maintained as needed for sanitary food service. The deficient practice could lead to the spread of foodborne illness for residents.Findings include:The Quarterly Ice Machine Inspection logs for ice machines on 300 A, 300 B, and 300 C common room dining areas revealed that the ice machines were last inspected and cleaned on June 6, 2025, by the maintenance director (Staff #40).An observation was conducted on October 7, 2025, at 11:50 A.M. of the three ice machines on the 300 unit, with one ice machine located in each of the three common room dining areas. Each of the three ice machines had a metallic-appearing housing box, and a clear plastic downspout for dispensing ice. Each of the three ice machine units had white-ish residue build-up on and around the clear plastic downspouts. One unit had brown-ish colored residue on the inside of the clear plastic downspout, and the other two units had multiple black spots of a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-05 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
1) Based on clinical record review, staff interviews and facility policy, the facility failed to ensure that medication side effects were monitored and documented for 2 residents (#84, #60) Findings include: Resident #84 was admitted with diagnoses of depression A care plan included that veteran displays inappropriate hand gestures and cursing towards staff and peers; 8/30/2023 Psychotropic meeting per wife with history of behaviors (no specific). 12/8/2023 verbal Aggressive Behavior towards peer. This care plan also included that this resident receives antidepressant medication : Sertraline for depression, dated 6/8/23. Sertraline increased 100 mg to 125 mg, 10/5/2023. Then increased to 150 mg. on 12/12/2023. Added Mirtazapine 7.5 mg PO QHS due to poor intake, then increased the Mirtazapine increased to 15 mg on 10/5/2023. This care plan included to monitor and report signs of sedation, hypotension, or anticholinergic symptoms. A physician's order dated 12/12/23 included Mirtazapine tablet 7.5 mg increased to 15 mg for a diagnosis of depression as evidenced by self-isolation,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-05 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen and properly store food products. The deficient practice could result in a potential for food borne illness. The resident census was 96. Findings include: During an initial walk-through of the kitchen on January 2, 2024 at 8:23 A.M a cell phone was observed sitting on a food preparation counter. Staff #120 (dining services director) removed the cell phone, once it had been brought to his attention. Additionally, during the initial walk-through staff #120 was observed walking through the kitchen without wearing a hairnet. In the food storage area, 2 dented cans were observed in the 'ready to use' area of the kitchen and not stored separately in the area specified for dented cans. These consisted of one can of marinara and another can of mushroom soup. An interview was conducted on January 4, 2024 at 7:57 A.M. with staff #120 (Dietary services director). Staff #120 stated that the expectation is that phones are not left on food service preparation areas, and that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-05 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide documentation of transfer notification for one resident. This had the potential for Residents and/or their representative to be unaware of their rights. Resident #6 was admitted to the facility on [DATE] with diagnoses that included Calculus of the Kidney, hypertension, Chronic Obstructive Pulmonary Disease (COPD), Mood disorder, and obesity. Review of resident #6's Electronic Health Record (EHR) indicated the resident was hospitalized on [DATE], September 20, 2023, November 13, 2023, and December 21, 2023. There was no evidence of a transfer notice being provided to the resident and/or their representative. Review of the discharge Minimum Data Set (MDS), dated [DATE] revealed the resident was not assessed for a Brief Interview for Mental Status (BIMS). The staff assessment indicated the resident's cognitive skills for daily decision making was independent. An interview was conducted with Social Services (staff #137) on January 4, 2024 at 1:50…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-09-30 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews, a food test tray, facility documents, and policy review, the facility failed to ensure residents consistently received food that was palatable. The deficient practice has the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals. Findings include: During interviews conducted with residents on September 27, 2022, one resident stated the kitchen cannot cook anything, the fries are frozen, and the meat is tough like shoe leather. Another resident stated the food is terrible. A third resident stated the food is horrible. Another resident stated since the change in food service, the food had been getting worse. A lunch test tray was ordered on September 29, 2022 and arrived at the unit at 11:15 a.m. The test tray consisted of pizza, green beans, and peach cobbler. The test tray was sampled by the survey team. The pizza had an overly crispy crust with toppings that had a rubbery texture. The green beans were mushy, and flavorless. Additionally, the green beans appeared to be teal-green in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · E2022-09-30 · tag F0806 — failed to honor food preferences — patternEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews, and grievances, the facility failed to ensure residents received food that accommodated the residents' preferences. The deficient practice could result in complications related to residents not eating and/or being disinterested in dining. Findings include: During interviews conducted with residents on September 27, 2022, a resident stated the facility does not serve what is on the menu and they are out of everything. Another resident stated the kitchen served the same meals all the time. Another resident stated the staff cannot get the 4-year standing order correct, that the kitchen either does not have it or they do not do as requested. An interview with the Dining Services Director (staff #105) was conducted on September 29, 2022 at 10:45 a.m. He stated that they provide residents with an alternate menu they can choose from if they do not want the item indicated on the scheduled menu. He stated he has only been on the job for a month. Staff #105 stated the menu is set by corporate so it is not changeable. He stated he informed the residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-09-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated, food items were not expired or moldy, and stored kitchenware was clean and dry. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding food labeling and dating: During the follow-up kitchen observation conducted on September 28, 2022 at 10:36 a.m., an opened sausage bag was observed not labeled with a use by or expiration date in the walk-in freezer. The Dining Services Director (staff #105) and the District Manager (staff #106) were present during the follow-up observation. The District Manager stated that there are different rules for frozen items and they can be kept longer. He stated that if it is unopened that it goes by the expiration date but it should have been marked with an opened date so that a use by date could be determined. The facility kitchen's policy titled Food Storage: Cold Foods revised September 2018 included that all foods will be stored wrapped or in a covered container, labeled, and dated.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, resident and staff interviews, and policy review, the facility failed to ensure one resident (#56) who was admitted with limited ROM (Range of Motion) was provided treatment and services to prevent further decrease in ROM/mobility. The sample size was 2. The deficient practice could result in residents experiencing decrease in ROM and functioning. Findings include: Resident #56 was admitted on [DATE] with diagnoses that included presence of right artificial hip joint, hemiplegia, affecting right side, and Type 2 diabetes mellitus with diabetic neuropathy. The annual Minimum Data Set assessment dated [DATE] revealed the resident long-term memory was ok, had short-term memory problems, could recall location of own room and staff names and faces, and had moderately impaired cognitive skills for daily decision making. The assessment also revealed the resident had impairment on one side of the upper extremity and lower extremity. A care plan initiated on August 18, 2022…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-30 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#24). The deficient practice could result in residents not receiving care and services for oral/dental conditions. Findings include: Resident #24 was initially admitted to the facility on [DATE] with diagnoses that included altered mental status, Alzheimer's disease, chronic obstructive pulmonary disease, and gastro-esophageal reflux disease. The social services portion of a care plan conference report dated October 7, 2021, indicated the resident had no teeth and did not want dentures. A physician progress note dated March 30, 2022, revealed the resident had no dentures and as a result the resident speech was unclear most of the time. Review of the Oral Cavity assessment dated [DATE] revealed the resident had no natural teeth or tooth fragments (edentulous). It also noted the resident had mouth or facial pain, discomfort or difficulty with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-09-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review, the facility failed to ensure an advanced directive was accurately documented for one sampled resident (#18). The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included dementia, nontraumatic intracranial hemorrhage, major depressive disorder, and chronic obstructive pulmonary disease. Review of the Advance Directive/Medical Treatment Decision form in resident #18's clinical record revealed the resident's power of attorney (POA) signed the form and indicated that the resident had not chosen to formulate an advance directive. The form was signed by the resident's POA and the facility representative on March 24, 2022. A physician's order dated March 24, 2022 stated Code Status: Full Code. However, further review of the clinical record revealed the MatrixCare dashboard indicated the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ARIZONA DEPARTMENT OF VETERANS SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/31/2011 |
| COADY, MAUREEN | Individual | W-2 MANAGING EMPLOYEE | — | since 10/31/2011 |
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
What families pay in AZ
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Arizona Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 035284. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.