Based on clinical review, facility documentation, staff interviews, policy and procedures, the facility failed to ensure one resident (#1) with a known suicidal ideation was provided with the treatment and services to attain his highest practicable mental and psychosocial well-being. Past non-compliance was identified and cited. The deficient practice resulted in self-harm and ultimately death of the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The PASSR (Pre-Admission Screening and Resident Review) Level 1 screening dated [DATE] included the resident had a serious mental illness [DIAGNOSES REDACTED]. …
F742 citations in Arizona
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Arizona cites F742 more often than its own record predicts
1.05 times the share F742 takes of citations nationally.
Of every deficiency written in Arizona in 2025, this is the portion that was F742.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Arizona surveyors wrote
F742 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 record review, interview, and policy review, the facility failed to provide the necessary behavioral health services and interventions for one of two residents (Resident (R) 60) reviewed for mental and psychosocial concerns by failing to evaluate, care plan, monitor, and address newly identified behavioral symptoms and suspected contributing psychosocial factors, despite staff recognition of changes in the resident's behavior and condition. This failure had the potential to cause R60 to experience worsening behavioral symptoms, unidentified underlying causes of the behavioral changes, increased social isolation, diminished psychosocial well-being, and adverse health and safety outcomes associated with untreated changes in mental and behavioral status.Findings include: 1. …
The short window
Recent years
| Year | Share of Arizona citations | vs expected |
|---|---|---|
| 2023 | 0.17% | 1.57× |
| 2025 | 0.13% | 1.05× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Arizona surveyors cite →
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