Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arizona State Veteran Home-tucson during CMS and state inspections, most recent first.
PBJ staffing data was not submitted accurately or in a timely manner. The BOM stated she was responsible for submitting the data and reported that it was sent near the deadline, but CMS later rejected it because the file was incorrect and the submission window had closed. The FAC stated the rejection may have involved incorrect codes, and the facility policy required quarterly staffing data to be reported through PBJ within the required timeframe.
Failure to Refer Resident With SMI for Level II PASRR Evaluation: A resident admitted with major depression, PTSD, psychotic disorder, and substance-use history was not referred for a Level II PASRR despite PASRR findings and psychotropic medication use documented in the record. The PASRR forms left key sections blank and concluded no Level II was needed, while SS and the DON stated the resident was stable and could be managed in-house. The facility policy stated residents who may meet criteria for a mental disorder or related condition were to be referred for Level II screening.
A resident with major depression, PTSD, psychotic disorder, and substance-use history was not referred for a Level II PASRR despite PASRRs and the clinical record documenting SMI and psychotropic medications. The PASRR forms were completed without key sections filled in and concluded that no Level II referral was needed, while SS and the DON stated the resident was stable and the IDT believed facility services were sufficient. The facility policy stated that residents who may meet criteria for a mental disorder, ID, or related condition were to be referred for Level II screening and evaluation.
A cognitively impaired resident receiving palliative care, with pneumonia and UTI, was involved in an incident where a visiting caregiver/companion threatened to wash the resident’s mouth out with soap after the resident used vulgar language, and had soap on her hands when the resident bit her fingers. Progress notes documented that a CNA reported the caregiver had put soap in the resident’s mouth because of cursing, and that this led to the bite. In interviews, a CNA confirmed that putting soap in a resident’s mouth is abuse, while the DON and Administrator, serving as abuse coordinator, acknowledged that it was not acceptable for visitors to threaten to put soap in residents’ mouths, in contrast to the facility’s abuse policy that guarantees residents freedom from verbal and physical abuse.
A resident with multiple medical conditions and intact cognition reported that a former staff member from the therapy department repeatedly solicited and received money from her, including payments for gas, meals, and a $1200 transfer via a banking app after she felt pressured. The resident stated this was not the first time she had given the staff member money and that she never received any of it back. The DON confirmed the allegation was substantiated and that the resident had not been reimbursed, despite facility policy stating residents must be free from abuse, exploitation, and misappropriation of property.
Three ice machines in common dining areas were found with visible residue and possible mold inside the dispensing downspouts, and had not been cleaned or inspected for several months. Staff interviews revealed confusion about cleaning responsibilities, with maintenance and housekeeping staff providing conflicting information about who cleans which parts of the machines. Facility policies and manufacturer instructions required more frequent and thorough cleaning, but these were not followed, resulting in unsanitary conditions.
The facility failed to monitor and document medication side effects for two residents, despite changes in psychotropic medications and a complex medical history. Staff interviews revealed a lack of orders and awareness for side-effect monitoring, contrary to the facility's policy.
The facility failed to maintain a clean and sanitary kitchen and properly store food products. A cell phone was found on a food preparation counter, and the dining services director was observed without a hairnet. Additionally, two dented cans were improperly stored in the 'ready to use' area. Interviews confirmed that these actions did not meet the facility's expectations and policies.
The facility failed to document transfer notifications for a resident with multiple hospitalizations, leading to potential unawareness of rights. Staff interviews revealed gaps in the notification process, and the DON confirmed the missing documentation.
PBJ Staffing Data Not Submitted Accurately or Timely
Penalty
Summary
The facility failed to ensure that Payroll-Based Journal (PBJ) staffing information submitted to CMS was accurate and submitted in a timely manner. During survey review, the PBJ Staffing Data Report for Fiscal Year Quarter 1, 2026 showed that the facility had failed to submit data for the quarter, and the survey team requested the PBJ staff data during the entrance meeting. The facility later provided the data that had been submitted to CMS. During interviews, the Business Office Manager stated that she was responsible for processing and submitting the PBJ data and said it had been submitted on February 13, 2026, one day before the stated deadline of February 14, 2026. She further stated that CMS later rejected the submission because the file was not the correct file and that the submission period had already closed by the time the rejection was discovered. The Facility Administrator stated that the rejection may have been due to incorrect codes, but the specific codes were not identified. The facility policy required staffing information to be collected daily and reported each fiscal quarter no later than 45 days after the end of the reporting quarter.
Failure to Refer Resident With SMI for Level II PASRR Evaluation
Penalty
Summary
The facility failed to coordinate and implement PASRR findings for one resident with serious mental illness by not ensuring a Level II PASRR evaluation was appropriately screened and referred when indicated. The resident was admitted with diagnoses including major depressive disorder, insomnia, PTSD, and psychotic disorder with hallucinations due to a known physiological condition. An admission PASRR dated March 10, 2025 identified a serious mental illness diagnosis of major depression and also noted a substance-related disorder, but the sections asking about a recent psychiatric or behavioral evaluation and psychotropic medications were left blank, and the form concluded that a Level II referral was not necessary. The resident’s admission MDS showed a BIMS score of 15, indicating cognitive intactness, and documented depression, psychotic disorder, PTSD, and use of antipsychotic and antidepressant medications. The clinical record also contained physician orders for Trazodone for inability to sleep due to depression, Venlafaxine for visual and auditory hallucinations related to PTSD, and Quetiapine for mood changes and insomnia due to PTSD. A second PASRR dated March 13, 2026 again identified serious mental illness diagnoses, including major depression and psychotic/delusional disorder, noted PTSD and remission for alcohol abuse, and listed Quetiapine, Trazodone, and Venlafaxine, yet it also stated that no Level II referral was needed. During interviews, the Social Services staff member stated that PASRRs were used to determine whether a resident needed Level II placement and said he involved the IDT when residents had behaviors or were taking mental health medications. He confirmed the resident had not been referred for Level II PASRR because he was stable and had no behavioral issues, and stated that the decision was made by the IDT. The DON also confirmed the resident had serious mental illness diagnoses and had not been referred for Level II PASRR, explaining that the facility did not refer residents if their needs could be met in-house and they were stable. The facility policy stated that if a Level I PASRR indicated a resident may meet criteria for a mental disorder, intellectual disability, or related condition, the resident was to be referred to the state PASRR representative for Level II screening and evaluation.
Failure to Refer Resident With SMI for Level II PASRR
Penalty
Summary
The facility failed to ensure that one resident with diagnoses including major depressive disorder, PTSD, psychotic disorder with hallucinations, and a substance-related disorder was appropriately screened and referred for a Level II PASRR evaluation when a serious mental illness was identified. The resident’s admission PASRR dated March 10, 2025 identified major depression as a SMI diagnosis and noted recent substance use, but sections addressing a recent psychiatric or behavioral evaluation and psychotropic medications were left blank. The form concluded that a Level II referral was not necessary and was signed by a hospital social worker. The resident’s admission MDS showed a BIMS score of 15, indicating cognitive intactness, and documented depression, psychotic disorder, PTSD, and use of antipsychotic and antidepressant medications. The clinical record also contained physician orders for Trazodone, Venlafaxine, and Quetiapine for symptoms related to depression, hallucinations, PTSD, mood changes, and insomnia. A second PASRR dated March 13, 2026 again identified SMI diagnoses including major depression and psychotic/delusional disorder, PTSD, and remission from alcohol abuse, and noted the resident was taking Quetiapine, Trazodone, and Venlafaxine; it also stated that no Level II referral was needed and was signed by Social Services. During interviews, Social Services staff explained that PASRR was used to determine whether a resident needed Level II placement and stated that referrals were not made if the resident had no behavioral issues, was stable, and the IDT determined services could be met in the facility. The DON similarly stated that a Level II referral was not needed if the resident’s needs could be met in the facility and the resident was stable. Review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring stated that if a Level I PASRR indicated a resident may meet criteria for a mental disorder, intellectual disability, or related condition, the resident was to be referred to the state PASRR representative for Level II screening and evaluation.
Failure to Protect a Cognitively Impaired Resident From Verbal Abuse by a Visitor
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a visitor. The resident was admitted with diagnoses including encounter for palliative care, pneumonia, and UTI, and had severely impaired cognitive skills for daily decision-making per a Quarterly MDS; a BIMS could not be completed, and no behavioral symptoms were documented. On one occasion, a CNA documented that the resident bit a caregiver’s right second finger during care. Later that same day, another progress note documented that a CNA reported the caregiver had put soap in the resident’s mouth because the resident was cursing, and that this was the reason the resident bit the caregiver. The house supervisor was notified of the incident. In interviews, a CNA stated that although veterans may swear frequently, staff and others cannot retaliate, and confirmed that putting soap in a resident’s mouth would constitute abuse. The caregiver, interviewed by phone, stated she had been hired by the resident’s wife as a companion caregiver to assist with cleaning and feeding, recalled a disagreement with the family, and reported having short-term memory loss and not remembering many details. The DON reported that the caregiver told the resident to be nice and stop using vulgar words and warned that people who curse get their mouths washed out with soap; the caregiver had soap on her hands when the resident lunged forward and bit the soap and her fingers. The Administrator, who served as the abuse coordinator, stated that a friend of the family had threatened to wash the resident’s mouth out with soap and confirmed that the resident bit the visitor. Both the DON and Administrator stated that it was not acceptable for visitors to threaten to put soap in residents’ mouths, and the facility’s abuse prevention policy stated that residents have the right to be free from abuse, including verbal and physical abuse.
Failure to Protect Resident From Financial Misappropriation by Former Staff
Penalty
Summary
The facility failed to protect a resident’s right to be free from misappropriation of property by allowing a pattern of financial exploitation by a staff member. The resident, who had diagnoses including bradycardia, atrial fibrillation, bipolar disorder, anxiety, dementia, and peripheral vascular disease, had a BIMS score of 15 on a significant change MDS assessment, indicating no cognitive impairment. According to a complaint reported to the state agency, the resident told her nurse that a former employee from the therapy department had been asking her for money. The former employee picked the resident up for lunch, during which the resident paid $55 to fill his gas tank and $35 for lunch. After returning to the facility, the former employee asked the resident for $1200, which she initially declined but then agreed to provide because she felt pressured. The resident reported that the former employee had her download a banking app on her phone and transfer $1200 to his account, and that this was not the first time she had given him money. She stated that she had been giving him money for various needs, such as rent, while observing that he was purchasing items like laptops instead of paying his rent. The resident confirmed that the bank called to verify the $1200 transaction and she approved it, later reporting the incident, which led to police involvement. She stated she never received any of the money back and that the facility did not reimburse her. The DON acknowledged awareness of the incident, confirmed that the investigation substantiated the allegation, and confirmed that the resident had not been reimbursed. Facility policy in effect stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
Failure to Maintain and Sanitize Ice Machines According to Standards
Penalty
Summary
The facility failed to ensure that three ice machines located in the 300 unit common room dining areas were cleaned and maintained according to professional standards and manufacturer instructions. Observations revealed that all three ice machines had visible white residue on and around the clear plastic downspouts, with one machine showing brown residue and two machines displaying multiple black spots resembling growth inside the downspouts. Further inspection of the interior of one ice machine revealed additional white residue inside the drum. The last documented cleaning and inspection of these machines was several months prior, as indicated by the facility's logs. Interviews with staff revealed inconsistencies and confusion regarding cleaning responsibilities and procedures. The maintenance director stated that he deep cleans the ice machines every six months and keeps a log, while housekeeping staff reported only cleaning the exterior surfaces during routine rounds. The housekeeping supervisor clarified that their department does not clean the inside parts of the machines, including the downspouts. Staff members, including an LPN and housekeeper, observed the black spots and residue and expressed uncertainty about their nature, with the LPN suggesting the black spots could be mold and stating she would not consume ice from the affected machine. Review of the facility's policies and the manufacturer's instructions indicated that more frequent cleaning, descaling, and sanitizing may be necessary depending on water conditions and visible residue. The policies emphasized the importance of maintaining ice machines to prevent contamination from microorganisms and waterborne pathogens. Despite these guidelines, the observed condition of the ice machines and staff interviews demonstrated a lack of adherence to established cleaning protocols, resulting in unsanitary conditions.
Failure to Monitor and Document Medication Side Effects
Penalty
Summary
The facility failed to ensure that medication side effects were monitored and documented for two residents, leading to deficiencies in care. Resident #84, who was admitted with a diagnosis of depression, had multiple changes in psychotropic medications, including increases in dosages of Sertraline and Mirtazapine. Despite these changes, there was no documentation in the clinical record that side effects of these medications were monitored. Interviews with staff revealed that there were no orders in place for monitoring the side effects, and the nurses were unaware of the need to chart for side effects in the absence of specific orders. This lack of monitoring could potentially result in unmonitored adverse side effects for the resident, who had a history of aggressive behavior and other symptoms of depression. The facility's policy on psychotropic medication use was not followed, as it requires adequate monitoring for efficacy and adverse consequences, which was not evident in the medical record for Resident #84. Similarly, Resident #60, who had a complex medical history including vascular dementia and major depressive disorder, was prescribed Fluoxetine for depression. The clinical record review revealed that there was no evidence of side-effect monitoring for this medication. Interviews with staff confirmed that there were no orders for monitoring side effects, and the nursing staff did not document any side effects in the MAR or TAR. The Director of Nursing acknowledged the absence of side-effect monitoring in the medical record, despite it being documented in the care plan. The facility's failure to monitor and document medication side effects for Resident #60 could lead to unmonitored adverse side effects, contrary to the facility's policy on psychotropic medication management.
Failure to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen and properly store food products. During an initial walk-through of the kitchen, a cell phone was observed sitting on a food preparation counter, which was later removed by the dining services director. Additionally, the dining services director was observed walking through the kitchen without wearing a hairnet. In the food storage area, two dented cans were found in the 'ready to use' area instead of being stored separately in the designated area for dented cans. These cans included one of marinara and another of mushroom soup. Interviews with the dietary services director and the administrator confirmed that the facility's expectations were not met. The dietary services director acknowledged that cell phones should not be left on food preparation areas and that hairnets should be worn at all times in the kitchen to prevent contamination. The administrator reiterated that everyone handling food needs to wear a hairnet and that cell phones should not be in the kitchen area due to the risk of germ transmission. Both staff members agreed that dented cans should not be utilized due to the potential risk of foodborne illness, including botulism. A review of the facility's policy on preventing foodborne illness confirmed these expectations.
Failure to Provide Transfer Notification
Penalty
Summary
The facility failed to provide documentation of transfer notification for one resident, which had the potential for residents and/or their representatives to be unaware of their rights. Resident #6, who had diagnoses including Calculus of the Kidney, hypertension, COPD, Mood disorder, and obesity, was hospitalized multiple times. However, there was no evidence of a transfer notice being provided to the resident or their representative for any of these hospitalizations. The discharge Minimum Data Set (MDS) indicated that the resident's cognitive skills for daily decision-making were independent, yet no Brief Interview for Mental Status (BIMS) was conducted. Interviews with staff revealed gaps in the notification process. Social Services staff stated that a bed hold form is reviewed with the resident or Power of Attorney (POA) when a resident is sent to the hospital, but no other forms are reviewed during this period. Medical records staff confirmed that documentation of transfer notification should be done in writing, but they were unable to locate such documentation for Resident #6. The Director of Nursing (DON) confirmed that the expected documentation was missing and acknowledged that the family should have been notified of the transfer, especially since the resident was independent in decision-making.
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Illustrative
What surveyors actually found near you
We read the 139 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tucson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sandstone Of Tucson Rehab Centre | 1.8 mi | ★★★★★ | 29 | 0 |
| Park Avenue Health And Rehabilitation Center | 4.7 mi | ★★★★★ | 0 | 0 |
| Catalina Post Acute And Rehabilitation | 5.3 mi | ★★★★★ | 3 | 0 |
| Santa Rosa Care Center | 6.1 mi | ★★★★★ | 2 | 0 |
| Villa Maria Post Acute And Rehabilitation | 6.1 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.