Severe reports

The report indicated that [Resident 3] contacted the Administrator, [Staff 2], and [Staff 2] directed [Staff 3] to take [Resident 1] to the emergency room for a "rape kit." The incident report further indicates that [Resident 2] and [Resident 3] were the alleged perpetrators of the assault. A review of the discharge paperwork from the hospital confirmed that [Resident 1] was evaluated for sexual assault and had contusions. In an interview over the telephone, [Staff 2] originally reported being unaware that there were any allegations of sexual or physical assault. [...] I need to speak to you asap because apparently a staff member sat and watch this happened and laugh... we really need the cameras." In an interview, [Staff 3] reported that [Staff 5] was the overnight behavioral health technician (BHT) and that [Resident 1] reported that [Staff 5] watched the assaults occur and did not intervene.

In an additional interview over the telephone, [Staff 2] reported never stating being unaware that there were any allegations of sexual or physical assault. [Staff 2] reported being aware only of the physical assault and not the sexual assault.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; R9-10-716.A.7.b. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or .... "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: Records showed residents earned money for cleaning. A child reported hearing rumors about a staff member and another child having a sexual relationship. An incident report noted a child wrapped a fan cord around their neck while staff were busy, leading to a restraint. During that restraint, a child reported a staff member twisted their wrist and forced them to the ground. Our summary of the state's report. The state's own wording follows.

[Resident 5]'s and [Resident 10]'s pages documented that on May 25, 2025 and June 7, 2025, [Resident 5] and [Resident 10] earned $20 per day each for "cleaning apartment," and $10 each on June 3, 2025 for "cleaning feet." 7.In an interview, [Resident 3] stated [Resident 5] is [Staff 1]'s "number one worker," and that [Resident 3] has heard rumors from multiple people regarding [Resident 5] and [Staff 1] being in a sexual relationship. [...] 9.In an interview, [Resident 5] reported other residents have made comments to [Resident 5] about [Resident 5] and [Staff 1] being in a sexual relationship.

A review of [Resident 4]'s medical record revealed a document titled, "Incident Report Form," dated May 25, 2025, which stated, "..There was a situation going on that had staff a bit pre-occupied and peer...went to talk to [Resident 4] and found [Resident 4] with a standing fan cord wrapped around [Resident 4's] neck. [Peer] yelled for staff...[Resident 4's] peer...came out of the room carrying the standing fan...[Resident 2] was sitting on the bed and [Staff 7] moved into escort [Resident 4]...[Resident 4] was put into a PCS restraint to escort [Resident 4] down the hall..." 7. [...] During this restraint [Resident 2] reported staff twisted [Resident 2]'s wrist and put [Resident 2] down to the ground, stating "it hurt." [Resident 2] also stated staff will use their hands or knee to hold the residents down on the floor "like police grabbing you." 10.

From the state's report. Deficiency cited, complaint. Cited: R9-10-716.A.7.a. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings ...; R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Resident [Resident 1] was brought to the therapist's office at approximately 1:30-1:40. [Resident 1] disclosed to the therapist that another peer was kissing [Resident 1] and asking [Resident 1] to engage in other sexual activity.

From the state's report. Deficiency cited, complaint. Cited: A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose .... The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In an interview, [Staff 1] acknowledged residents were admitted to the behavioral health residential facility with previous sexual abuse as well as residents with previous sexual aggression.

From the state's report. Deficiency cited, complaint. Cited: A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or treatment, or verbally or physically interact .... The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

1. A review of facility documentation revealed an Arizona Health Care Cost Containment System (AHCCCS) incident report dated July 9, 2024 for an incident of sexual abuse reported on July 5, 2024. The report indicated suspected sexual abuse of [Resident 1] by [Staff 5]. The report stated "On 7/6, the member reported to a staff member that on 7/5, a staff member has inappropriate sexual contact with [Resident 1]." 2.

From the state's report. Deficiency cited, complaint. Cited: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

[Staff 2] reported to have written incident reports on "two or three" occasions regarding [Resident 1]'s unwanted sexual misconduct behavior allegations by another resident towards [Resident 1].

From the state's report. Deficiency cited, complaint. Cited: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose .... The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.