Cycle 1
Health 2025-05-30 · Fire 2025-05-30
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Phoenix, AZ
Arizona State Veteran Home-Phx
1-star overall rating with 1-star inspections with abuse icon flag with $23,296 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
4141 North S Herrera Way, Phoenix, AZ
(602) 248-1550
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
200
Certified beds
Average residents
92
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-01-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.20
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
3.56
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
5.75
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.19
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
5.06
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.98
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.40
CMS adjusted RN staffing hours
Adjusted total hours
6.72
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 99 |
| Staff flu vaccination coverage | 24% |
42%
18 pts worse
|
Numerator 24 · Denominator 100 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.0% |
97.1%
13.1 pts worse
|
93.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.7% · Q2 84.5% · Q3 83.6% · Q4 85.7% · 4Q avg 84.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.0% |
94.6%
3.6 pts worse
|
95.5%
4.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
2.1%
0.1 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 1.5% · Q4 2.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.8% |
4.2%
1.6 pts worse
|
11.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.8% · Q3 3.6% · Q4 8.8% · 4Q avg 5.8% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.3%
1.6 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.9% · Q3 0.0% · Q4 3.1% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
20.5%
5.2 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 16.7% · Q3 15.8% · Q4 15.8% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.6% |
11.8%
1.8 pts worse
|
16.7%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 13.6% · Q3 15.0% · Q4 16.0% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.9% |
14.5%
6.4 pts worse
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.4% |
10.8%
11.6 pts worse
|
14.9%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 26.9% · Q3 20.8% · Q4 19.1% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.9% |
1.2%
8.7 pts worse
|
1.7%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 7.0% · Q3 7.5% · Q4 12.0% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.9% |
20.5%
1.6 pts better
|
19.8%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 24.3% · Q3 16.7% · Q4 17.0% · 4Q avg 18.9% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
4.8%
3.2 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 10.7% · Q3 4.9% · Q4 4.2% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.1% |
91.1%
21 pts worse
|
81.7%
11.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.0% · Q2 73.9% · Q3 71.1% · Q4 69.4% · 4Q avg 70.1% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.4% |
1.1%
4.3 pts worse
|
1.6%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.0% |
87.3%
27.3 pts worse
|
79.7%
19.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-21 · Fire 2023-07-21
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2022-05-26 · Fire 2022-05-26
16 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-30
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-05-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-05-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-05-30
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-30
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-30
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-07-01
E · Potential for more than minimal harm
2023-07-21
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-07-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-07-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-01
D · Potential for more than minimal harm
2022-05-26
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-06-20
D · Potential for more than minimal harm
2022-05-26
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2022-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-15
F · Potential for more than minimal harm
2025-05-30
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-05-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-05-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-05-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-04-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-02-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-21
G · Actual harm
2025-01-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-01-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-21
D · Potential for more than minimal harm
2024-12-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-05
D · Potential for more than minimal harm
2024-10-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-03
E · Potential for more than minimal harm
2024-09-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-05-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-05-24
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-07-25
G · Actual harm
2024-05-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-15
D · Potential for more than minimal harm
2024-04-22
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-04-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-01-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-01-12
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-04-12
D · Potential for more than minimal harm
2023-11-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-25
G · Actual harm
2023-11-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-11-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-01
D · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-18
E · Potential for more than minimal harm
2023-07-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-09-20
E · Potential for more than minimal harm
2023-07-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-21
D · Potential for more than minimal harm
2023-07-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-07-21
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-09-20
D · Potential for more than minimal harm
2023-07-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-03-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-31
E · Potential for more than minimal harm
2022-05-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-05-26
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-26
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-26
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2022-06-17
Penalties and ownership
What sits behind the stars
$9,110
2024-12-10
Fine
Fine · fine $9,110
Fine
$6,743
2024-04-22
Fine
Fine · fine $6,743
Fine
$0
2024-04-22
Payment Denial
Payment Denial · denial start 2024-07-22 · 3 days
3 day denial
$7,443
2023-11-02
Fine
Fine · fine $7,443
Fine
Ownership
Garcia, Justina
W-2 Managing Employee · Individual
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