Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arizona State Veteran Home - Yuma during CMS and state inspections, most recent first.
A resident with multiple health conditions received Diltiazem HCL outside of prescribed parameters, leading to a deficiency in medication administration. Despite being cognitively intact, the resident experienced falls and balance issues, which they attributed to low blood pressure. Facility staff acknowledged the lack of documentation for administering medication outside of physician orders, highlighting the importance of following medication protocols.
A resident with chronic kidney disease and diabetes was subjected to abuse by another resident who threw coffee on him for moving too slowly. Despite previous reports of bullying, the facility failed to implement effective measures to prevent the abusive behavior. The abusive resident, with a history of PTSD and Major Depressive Disorder, admitted to the act and showed no remorse. Staff interviews revealed a pattern of bullying behavior that was not adequately addressed, leading to a deficiency in protecting residents from abuse.
The facility did not submit required PBJ data to CMS for two consecutive quarters. The Assistant Director, responsible for this task, cited the absence of a Medicare number as a reason for not submitting data for one quarter and acknowledged the failure to submit for the subsequent quarter. This omission could affect the facility's staffing star rating.
The facility failed to provide consistently warm and palatable food to residents, as evidenced by grievances and resident council complaints over six months. A test tray confirmed food was served below expected temperatures, and interviews with residents and staff highlighted the impact of cold food. The facility's policy on serving food at safe and appetizing temperatures was not followed.
The facility's kitchen was found to have multiple sanitation and food labeling deficiencies, including expired and improperly stored food items, a malfunctioning soap dispenser, and a dusty fan. Observations revealed improperly labeled food in unit refrigerators, posing a risk of contamination. Staff interviews confirmed lapses in food safety practices.
A facility failed to prevent abuse between residents, resulting in a physical altercation where one resident was scratched by another. Despite having care plans, the facility delayed reporting the incident to authorities and lacked documentation of a skin assessment. Additionally, verbal abuse occurred between two other residents, with staff intervening but not following abuse reporting policies promptly.
A facility failed to report an abuse allegation within the required timeframe, involving an altercation where a resident was scratched and threatened by another. The report to the state agency was delayed, and documentation was lacking. Additionally, the facility did not effectively implement policies to prevent abuse in a separate incident involving verbal threats between two residents, with inadequate separation and delayed reporting.
A facility failed to ensure accurate documentation of a resident's code status, resulting in a discrepancy between the physician's order for full code and the face sheet indicating DNR. The resident, with a history of serious health conditions, had communication barriers, and the miscommunication between staff led to conflicting documentation. Interviews with staff, including the DON and Nurse Supervisor, revealed a lack of clarity and adherence to the facility's policy on advance directives.
Medication Administration Error Leads to Deficiency
Penalty
Summary
The facility failed to ensure a drug regimen free from unnecessary medications for a resident, leading to the administration of Diltiazem HCL outside of prescribed parameters. The resident, who was admitted with diagnoses including diabetes, hypertension, chronic kidney disease-stage 4, macular degeneration, and muscle weakness, experienced multiple falls and balance instability during their stay. Despite being cognitively intact and using a walker for mobility, the resident received doses of Diltiazem HCL on several occasions when their pulse was below the prescribed threshold of 60 beats per minute. Interviews with the resident and facility staff revealed that the resident believed their falls were due to low blood pressure, and they expressed confidence in the facility's staff despite the medication errors. The facility's compliance officer and Director of Nursing acknowledged the lack of documentation supporting the administration of medication outside of physician orders and recognized the increased risk of falls associated with blood pressure medications. The facility's policies on medication administration and managing falls emphasize the importance of following physician orders and monitoring vital signs to prevent adverse consequences.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in an incident where one resident threw coffee onto another resident's lap. The incident occurred when the resident was self-propelling to the dining room and was confronted by another resident who threw coffee at him for moving too slowly. The resident who was attacked had a BIMS score indicating cognitive intactness and had been admitted with chronic kidney disease, type 2 diabetes, and generalized muscle weakness. The incident was documented by a registered nurse, and it was noted that the resident's wife requested charges to be filed due to previous bullying incidents by the same resident. The resident who committed the act of abuse was also cognitively intact, with a history of hypertension, Stage 4 kidney disease, PTSD, and Major Depressive Disorder. The resident admitted to pouring coffee on the other resident and expressed no regret for his actions. Interviews with staff and other residents revealed a pattern of bullying behavior by the abusive resident, who had been known to assert authority and control over others. Despite previous reports of bullying, staff indicated that no significant changes were made to address the behavior, and the abusive resident continued to interact with others without adequate supervision. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the ongoing bullying and the eventual physical assault. Staff interviews revealed that the abusive resident had a history of verbal aggression and low patience for slower-moving residents, yet there was no perception of him being a physical threat. The facility's failure to adequately monitor and address the abusive behavior led to the incident, highlighting a deficiency in ensuring residents' right to be free from abuse.
Failure to Submit PBJ Data for Two Quarters
Penalty
Summary
The facility failed to submit the required direct care staffing information and CASPER Payroll-Based Journal (PBJ) data to the Centers for Medicare & Medicaid Services (CMS) for two consecutive quarters. This deficiency was identified through observations, facility documentation, staff interviews, and policy review. Specifically, the facility did not submit data for the second quarter of the fiscal year 2024 (January 1st - March 31st) and the third quarter (April 1st - June 30th). During an interview, the Assistant Director, who is also the Staffing and Payroll Coordinator, acknowledged the expectation to submit the PBJ report quarterly. The Assistant Director explained that the facility did not have a Medicare number until April 2024, which was cited as a reason for not submitting the data for the second quarter. However, the Assistant Director admitted awareness of the requirement to submit data for the third quarter but failed to do so. The Assistant Director also recognized that not submitting the PBJ data could impact the facility's star rating on staffing.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable and warm, as evidenced by multiple grievances and complaints from residents over a six-month period. Grievances documented issues such as cold food temperatures, tough meat, and unappetizing meals. Specific complaints included cold lunches, preferences about desserts not being met, and meals missing ingredients. Resident council meeting notes further highlighted issues with food temperatures, undercooked foods, and meals missing ingredients. A test tray ordered by the survey team confirmed these issues, with food items such as mashed potatoes, meatloaf, and steamed vegetables being served at temperatures below the expected standards, and the food was deemed not palatable or appetizing. Interviews with residents and staff corroborated the findings of the survey team. A resident reported that food temperatures varied and were sometimes cold. The Kitchen Director expressed concerns about the impact of cold food on residents, particularly the elderly, and noted that some units lacked hot plates, which contributed to the problem. Observations during food preparation and tray line service showed that while food was initially prepared at appropriate temperatures, it was not maintained by the time it reached residents, as evidenced by the test tray results. The facility's policy on Food and Nutrition Services, which mandates that food be served at a safe and appetizing temperature, was not adhered to, leading to dissatisfaction and potential nutritional issues for residents.
Sanitation and Food Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment, as evidenced by multiple observations of expired and improperly stored food items. During a walk-in cooler inspection, several iceberg lettuce items were found with brownish spotting, white/gray fuzzy growth spots, and slimy liquid substances. Bell peppers exhibited similar white/gray fuzzy growth and blackish spots, while an apple had a mushy spot. Additionally, the pantry contained expired brown sugar. Interviews with dietary staff revealed that these items should have been discarded, indicating a lapse in food safety practices. Further observations highlighted additional sanitary issues, including a malfunctioning soap dispenser near the dishware sink, a dusty fan in use, and food crumbs on cups in the dishware rack. The walk-in cooler contained drinks that were not properly labeled with necessary information such as the date made, item name, and expiration date. The pantry had a spaghetti package with a rip exposing the pasta, and the refrigerator contained expired Teriyaki sauce. Unit refrigerators also had improperly labeled food items, lacking details like the date received, resident name, and expiration date. Interviews with staff confirmed that these labeling practices were not being followed, posing a risk of food contamination.
Failure to Prevent Resident Abuse and Inadequate Response
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Video footage and interviews revealed that an incident occurred between two residents, where one resident physically grabbed and scratched the other. The affected resident reported the incident to staff, but there was a delay in reporting the incident to the appropriate authorities. The facility's documentation was inconsistent, with missing records of a skin assessment following the altercation. The resident who was attacked had a history of dementia and other medical conditions, and was using a wheelchair for mobility. Despite having a care plan in place to monitor for signs of distress, the resident experienced increased blood pressure following the incident. The facility's response included notifying the Director of Nursing and conducting interviews, but there was a lack of immediate documentation and assessment of the resident's injuries. Additionally, the facility failed to prevent verbal abuse between two other residents. Both residents exchanged profane language, and one resident threatened the other. Staff intervened to separate the residents, but the facility's policy on abuse reporting was not followed promptly. Interviews with staff highlighted the potential impact of abuse on residents, including fear and isolation, but the facility's response to the incidents was inadequate, as evidenced by the delayed reporting and lack of thorough investigation.
Failure to Timely Report and Address Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not reporting an allegation of abuse within the required timeframe for a resident. This deficiency was identified through clinical record reviews, staff interviews, facility documentation, and policy review. The incident involved an altercation between two residents, where one resident reported being scratched and verbally threatened by another resident. The incident was reported to a Licensed Practical Nurse (LPN) during medication rounds, but the report to the state agency was delayed, not occurring until the following morning. The facility's policy requires that allegations of abuse be reported to the state agency within two hours if there is harm, or within 24 hours otherwise. However, the report was not made until several hours after the incident, and the facility was unable to produce documentation of a skin audit or shower sheets for the month of the incident. Interviews with staff revealed that the Director of Nursing (DON) and the Administrator were informed of the incident the morning after it occurred, and the abuse reporting procedures began only after the DON gathered details to determine if the incident was reportable. Additionally, the facility failed to ensure that policies and procedures to prevent abuse were implemented for two other residents involved in a separate incident. This incident involved verbal threats and altercations between the residents, with one resident threatening another. The facility's response included separating the residents and conducting an investigation, but the interventions were not fully effective as the residents were not adequately separated. The facility's policy requires immediate reporting and investigation of abuse allegations, but the response to this incident was also delayed, and the interventions were insufficient to prevent further altercations.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure that the code status of a resident was accurately documented and communicated, leading to a discrepancy between the physician's orders and the resident's face sheet. The resident, who had a history of epilepsy, hallucinations, sequelae of cerebral infarction, and Parkinson's disease, was admitted with a Do Not Resuscitate (DNR) status on the face sheet, while the physician's order indicated a full code status. This discrepancy was identified during a review of the resident's clinical records and interviews with staff members, revealing a lack of clarity and communication regarding the resident's advance directives. Interviews with various staff members, including practical nurses, the Admission Coordinator, the Nurse Supervisor, and the Director of Nursing (DON), highlighted the confusion and miscommunication surrounding the resident's code status. The Nurse Supervisor admitted the resident and documented the admission, but there was a miscommunication with the night shift nurse, who did not follow the advanced directive documentation before entering the DNR status. The DON confirmed the discrepancy and acknowledged the risk of not abiding by the resident's wishes, which could be devastating to the family. The facility's policy requires that any changes in advance directives be communicated to the physician for accurate documentation, but this was not adhered to in this case.
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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.
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Nursing homes near Yuma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haven Of Yuma | 5.9 mi | — | 0 | 0 |
| Haven Of Sandpointe, Llc | 6.6 mi | — | 1 | 0 |
| Yuma Nursing Center | 7.1 mi | — | 0 | 0 |
| Life Care Center Of Yuma | 7.1 mi | — | 6 | 0 |
| Welbrook Yuma Opco Llc | 7.1 mi | — | 5 | 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 August 2026) and official state health department websites.