Based on observation, interviews, and record review, the facility failed to provide adequate supervision and follow its elopement policy for 1 of 1 resident (R1) reviewed for supervision. This failure resulted in R1 remaining alone outdoors for approximately 4 hours in extreme heat conditions (100 Fahrenheit (F) - 111 F, with a heat index of up to 114 F). (Heat index is defined as a measurement that combines air temperature and relative humidity to determine how hot the air actually feels to the human body.) The deficient practice placed the resident at risk for heat exhaustion, heat stroke, and/or death and resulted in a situation of immediate jeopardy.On [DATE] at 5:30 PM the Administrator and Assistant Administrator were notified of an Immediate Jeopardy determination for [DATE] for 42… …
F689 citations in Arizona
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Arizona cites F689 more often than its own record predicts
1.31 times the share F689 takes of citations nationally.
Of every deficiency written in Arizona in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Arizona surveyors wrote
F689 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 observations, interviews, clinical record review, weather data review, and review of facility policy and procedure, the facility failed to provide adequate supervision for one resident (#109) who was assessed to have poor safety awareness and required assistance with mobility, while in the courtyard during extreme summer temperatures. Sampled residents for accidents were 3. As a result, Resident #109 remained outdoors for an undetermined period of time in temperatures reaching 103 F and sustained second-degree burns to both thighs requiring emergency medical treatment at the hospital.Findings include:Resident #109 was readmitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, muscle weakness, cognitive communication… …
Based on interviews, observations, clinical record review, and review of facility policy and procedure, the facility failed to provide adequate supervision to prevent an accident for one (#97) of three sampled residents reviewed for accidents and supervision, resulting in an injury requiring hospital evaluation and treatment. The deficient practice could result in residents sustaining injuries due to inadequate supervision.Findings Include:Resident #97 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, dysphagia following nontraumatic subarachnoid hemorrhage, morbid (severe) obesity, anxiety disorder, muscle weakness, unspecified abnormalities of gait and mobility, and… …
The short window
Recent years
| Year | Share of Arizona citations | vs expected |
|---|---|---|
| 2023 | 5.56% | 1.12× |
| 2024 | 7.20% | 1.34× |
| 2025 | 7.27% | 1.31× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Arizona surveyors cite →
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