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Source: AZ State Licensing Agency
No deficiencies were found during the on-site compliance inspection conducted on November 14, 2025.
The following deficiencies were found during the on-site compliance inspection conducted on July 11, 2023:
Based on record review and interview, the manager failed to ensure a resident had a written service plan, when updated, signed and dated by the resident or resident's representative and the manager, for one of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed a service plan dated in June 2023 for personal care services. However, the service plan was not signed and dated by the resident or the manager. 2. In an interview, E1 acknowledged the service plan for R1 had not been signed and dated by the resident or the manager.
Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed. Findings include: 1. A review of the facility documentation revealed an undated document titled "FALLS PREVENTION AND FALL RECOVERY TRAINING POLICY AND PROCEDURE." However, the training policy and procedure did not include the initial training and continued competency training requirement. 2. In an interview, E1 acknowledged the facility's fall prevention and fall recovery training program did not include the initial training and continued competency training requirement.
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