Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure a baseline care plan was provided to resident/representative for 3 of 25 sampled residents (#168, #171 and #175). The deficient practice could result in residents not receiving the necessary care and services to meet their assessed needs upon admission.Findings include:-Resident #168 was admitted on [DATE] with diagnoses of acute posthemorrhagic anemia, unsteadiness of feet, difficulty of walking, seizures, and COPD (chronic pulmonary obstructive disease). The nursing note dated October 23, 2023 included that resident arrived from the hospital, was alert and oriented x 4 and was able to make needs known. Per the documentation all consents were signed by the resident. …
F655 citations in Arizona
Baseline care plan · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Arizona cites F655 less often than its own record predicts
0.97 times the national share — cited less often here than elsewhere.
Of every deficiency written in Arizona in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Arizona surveyors wrote
F655 findings written in Arizona, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on clinical record review, resident and staff interviews, and policy, the facility failed to ensure one resident (#57) and their representative was provided with a summary of the baseline care plan. Findings include: Resident #57 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Care Conference note dated 6/21/2018 revealed the resident was not in the facility when his admission care plan conference was scheduled. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a BIMs (Brief Interview for Mental Status) score of 14 which indicated the resident was cognitively intact. …
The short window
Recent years
| Year | Share of Arizona citations | vs expected |
|---|---|---|
| 2023 | 0.87% | 1.09× |
| 2024 | 0.61% | 0.89× |
| 2025 | 0.64% | 0.97× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Arizona surveyors cite →
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