Arizona State Veteran Home-Tucson

In the surveyor’s words

From the most serious findings on record at Arizona State Veteran Home-Tucson, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Apr 10, 2026

  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. […]

• No harm, potential for more than minimal, patternF812Nov 13, 2025

  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. […]

• No harm, potential for more than minimal, patternF758Jan 5, 2024

  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. […]

• No harm, potential for more than minimal, patternF812Jan 5, 2024

  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. […]

• No harm, potential for more than minimal, patternF804Sep 30, 2022

  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. […]