Based on observation, interviews, facility documentation, policy review, and the State Agency complaint tracking system, the facility failed to ensure that one resident (#1) was not neglected by failing to assess and meet their basic needs to prevent the development of a Stage 3 pressure ulcer and Deep Tissue Injury (DTI). The deficient practice could result in the residents' development of pressure ulcers and deep tissue injuries.Findings include:Resident #1 was admitted to the facility on [DATE], with diagnoses that included hypertension, Diabetes Mellitus (DM) Type 2, Schizophrenia, Non-Alzheimer's Dementia, and Cerebrovascular Accident (CVA) with a left-sided weakness.On May 9, 2025, a Braden Scale for Predicting Pressure Sore Risk assessment was completed, and the resident's score was… …
F686 citations in Arizona
Pressure ulcers · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Arizona cites F686 less often than its own record predicts
0.52 times the national share — cited less often here than elsewhere.
Of every deficiency written in Arizona in 2025, this is the portion that was F686.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Arizona surveyors wrote
F686 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, observations, interviews, and review of the facility's policies and procedures, the facility failed to ensure one resident, #4, was monitored and assessed for changes in her condition. The universe was 21. The deficient practice could lead to residents having an adverse health event as a result of not being monitored adequately.Findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, type 2 diabetes, dysphagia, and renal and perinephric abscess.An admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 08 which indicated Resident #4 had moderate cognitive impairment. …
The short window
Recent years
| Year | Share of Arizona citations | vs expected |
|---|---|---|
| 2023 | 2.26% | 1.10× |
| 2024 | 0.92% | 0.44× |
| 2025 | 1.02% | 0.52× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Arizona surveyors cite →
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