Based on interview and record review the facility failed to develop a Compliance and Ethics Program. Findings: During the survey non-compliance at F610, investigate alleged abuse violation revealed the facility did not consistently follow their own policies. A review of the Facility Assessment revealed a lack of information regarding a Compliance and Ethics Program. During an interview on 09/15/23 at 8:51 AM the Director of Nursing was asked if the facility had a Compliance and Ethics Program. She stated, No, we do not have one. She further stated she was not aware of the requirement. During an interview on 09/15/23 at 9:00 AM the Chief Executive Officer, the appointed Administrator for the facility, was asked if there was a Compliance and Ethics Programs. …
F895 citations in Arizona
Administration Deficiencies
Have a Compliance and Ethics Program.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2023
Arizona cites F895 more often than its own record predicts
10.07 times the share F895 takes of citations nationally.
Of every deficiency written in Arizona in 2023, this is the portion that was F895.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Arizona surveyors wrote
F895 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.
What else Arizona surveyors cite →
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