summary: Compliance (Annual) - 5/16/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on May 16, 2023:

rule: B. An administrator shall ensure that: 2. A personnel member's skills and knowledge are verified and documented: a. Before the personnel member provides physical health services or behavioral health services, and b. According to policies and procedures; and

evidence: Based on observation, record review, and interview, the administrator failed to ensure personnel members' skills and knowledge were verified and documented before the personnel member provided behavioral health services.

findings: 1. The compliance officer observed E2 working at the facility at the time of the inspection. 2. A review of E2 and E3's personnel record revealed no documentation of verification of skills and knowledge. 3. In an interview, E1 reviewed E2 and E3's record. E1 reported E1 completed orientation with E2 and E3. E1 acknowledged the identified personnel records did not contain documentation of the reported verification of skills and knowledge. E1 acknowledged the administrator failed to ensure personnel members' skills and knowledge were verified and documented before the personnel member provided behavioral health services.

rule: E. An administrator shall ensure that: 3. An individual's orientation is documented, to include: a. The individual's name, b. The date of the orientation, and c. The subject or topics covered in the orientation;

evidence: Based on record review and interview, the administrator failed to ensure an individual's orientation was documented.

findings: 1. A review of E2 and E3's personnel records revealed no documentation of E2 and E3's orientation was documented. Based on E2 and E3's dates of hire as Behavioral Health Technicians, documentation of orientation was required. 2. In an interview, E1 reported orientation was completed for the personnel identified. E1 acknowledged E2 and E3's personnel records did not include documentation of the orientation provided.

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's compliance with the requirements in A.R.S. \'a7 36-425.03.

findings: 1. A review of E3's personnel record revealed a valid fingerprint clearance card, or documentation of an application for a fingerprint clearance card, was not available for review. Based on E3's date of hire, this documentation was required. 2. In an interview, E1 reported E1 believed E3 did have a valid fingerprint clearance card however acknowledged there was no documentation of the fingerprint clearance card or good faith effort to verify said fingerprint clearance card. E1 acknowledged the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's compliance with the requirements in A.R.S. \'a7 36-425.03.

rule: J. An administrator shall ensure that the following personnel members have first-aid and cardiopulmonary resuscitation training specific to the populations served by the behavioral health residential facility: 1. At least one personnel member who is present at the behavioral health residential facility during hours of operation of the behavioral health residential facility, and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure at least one personnel member present at the behavioral health facility during hours of operation had cardiopulmonary resuscitation training (CPR).

findings: 1. A review of the facilities personnel schedule revealed that E2 worked alone with residents on from 6 am to 3pm on May 8, 2023 and May 9, 2023. 2. A review of E2's personnel record revealed an online cardiopulmonary resuscitation training completed on January 25, 2022 from the NationalCPRFoundation. 3. In an interview, E2 acknowledged E2 worked alone with residents on the dates identified. E2 acknowledged E2 completed online CPR training. 4. E1 reviewed E2's personnel record and acknowledged the certification revealed an online CPR certification. E1 acknowledged the administrator failed to ensure at least one personnel member present at the behavioral health facility during hours of operation identified had cardiopulmonary resuscitation training.

rule: K. An administrator shall ensure that: 3. There is a daily staffing schedule that: a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members; b. Includes documentation of the employees who work each calendar day and the hours worked by each employee; and c. Is maintained for at least 12 months after the last date on the documentation;

evidence: Based on observation, documentation review, and interview, the administrator failed to ensure there was a daily staffing schedule which indicated the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members, included documentation of the employees who worked each calendar day and the hours worked by each employee, and was maintained for at least 12 months after the last date on the documentation.

findings: 1. Upon arrival at the facility, the compliance officer observed E2 working. 2. A review of the facility's staffing schedule revealed a schedule conspicuously posted on the facility bulletin board with the dates of April 17, 2023 through May 14, 2023. The document identified E4 worked at the facility April 25, 2023 through May 8, 2023. However, E4's date of termination was April 24, 2023. A request for the facility's personnel schedule for the last twelve months revealed no additional schedules were available for review. 3. In an interview, E1 acknowledged the daily staffing schedule posted identified a personnel member who no longer worked for the facility. E1 acknowledged the current staffing schedule was the only staffing schedule available for review for a twelve month period. E1 reported E1 was not aware the personnel schedule was required to be maintained for a twelve month period. E1 acknowledged the administrator failed to ensure there was a daily staffing schedule which indicated the date, scheduled work hours, and name of each employee assigned to work included documentation of the employees who worked each calendar day and the hours worked by each employee, and was maintained for at least 12 months after the last date on the documentation.

rule: A. An administrator shall ensure that: 6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission;

evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission.

findings: 1. A review of R1 and R2's medical records revealed no medical history or physical examination. Based on the residents' dates of acceptance, this documentation was required. 2. In an interview, E1 reviewed R1 and R2's medical records. E1 acknowledged R1 and R2's medical records did not include a medical history or physical examination.

rule: A. An administrator shall ensure that: 8. If a behavioral health assessment is conducted by a: a. Behavioral health technician or registered nurse, within 24 hours a behavioral health professional, certified or licensed to provide the behavioral health services needed by the resident, reviews and signs the behavioral health assessment to ensure that the behavioral health assessment identifies the behavioral health services needed by the resident; or

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment conducted by a behavioral health technician or registered nurse, within 24 hours a behavioral health professional (BHP) certified or licensed to provide the behavioral health services needed by the resident, reviewed and signed the behavioral health assessment to ensure the behavioral health assessment identified the behavioral health services needed by the resident, for two of two residents sampled.

findings: 1. A review of R1's medical record revealed a behavioral health assessment completed by E1. The assessment did not include within 24 hours a behavioral health professional (BHP) reviewed and signed the behavioral health assessment. 2. A review of R2's medical record revealed behavioral health assessment completed by E1. The assessment did not include within 24 hours a behavioral health professional (BHP) reviewed and signed the behavioral health assessment. 3. In an interview, E1 reported E1 completed R1 and R2's behavioral health assessment. E1 reported the behavioral health professional did review the identified assessments. E1 reported E1 was unaware the behavioral health assessment required documentation the assessments were reviewed and signed by a Behavioral Health Professional within twenty-four hours.

rule: A. An administrator shall ensure that: 11. A behavioral health assessment: b. Includes: iii. The signature and date signed of the personnel member conducting the behavioral health assessment; and

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment included the signature and date signed of the personnel member conducting the behavioral health assessment, for two of two residents sampled.

findings: 1. A review of R1 and R2's medical records revealed behavioral health assessments. However, the signature and date signed of the personnel member who conducted the behavioral health assessments was not included. 2. In an interview, E1 reported E1 completed R1 and R2's behavioral health assessments. E1 reported E1 was unaware of the rule requirements. E1 acknowledged R1 and R2's behavioral health assessments was not signed and dated by the personnel member who conducted the behavioral health assessment.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: f. The signature of the personnel member who developed the treatment plan and the date signed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident that included the signature of the personnel member who developed the treatment plan and the date signed, for two of two residents sampled.

findings: 1. A review of R1's medical record revealed a treatment plan dated September 16, 2022. The treatment plan was completed by E1. The treatment plan did not include the signature of the personnel member who developed the treatment plan and the date signed. 2. A review of R2's medical record revealed a treatment plan dated November 7, 2022. The treatment plan was completed by E1. The treatment plan did not include the signature of the personnel member who developed the treatment plan and the date signed. 3. In an interview, E1 acknowledged the treatment plans for R1 and R2 were completed by E1. E1 acknowledged the treatment plans did not include the signature of the personnel member who developed the treatment plan and the date signed.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident that, if completed by a behavioral health technician, was reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan was complete and accurate and met the resident's treatment needs.

findings: 1. A review of R1's medical record revealed a treatment plan dated September 16, 2022. The treatment plan was completed by E1, behavioral health technician. The treatment plan completed by E1 did not reveal documentation the treatment plan was reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan was complete and accurate and met the resident's treatment needs. 2. A review of R2's medical record revealed a treatment plan dated November 7, 2022. The treatment plan was completed by E1, behavioral health technician. The treatment plan completed by E1 did not reveal documentation the treatment plan was reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan was complete and accurate and met the resident's treatment needs. 3. In an interview, E1 acknowledged the treatment plans for R1 and R2 were completed by E1. E1 acknowledged the treatment plans did not reveal documentation the treatment plan was reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan was complete and accurate and met the resident's treatment needs.

rule: C. An administrator shall ensure that a resident's medical record contains: 4. The date of admission and, if applicable, date of discharge;

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained the date of discharge, for two of two discharged residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. A review of R1's and R2's medical records revealed no date of admission was available for review. 2. In an interview, E1 reviewed R1 and R2's medical records. E1 reported the date of admission was the date consent for treatment was signed. E1 acknowledged R1's and R2's medical records did not contain R1's and R2's dates of admission.

rule: C. An administrator shall ensure that: 2. Each counseling session is documented in a resident's medical record to include: e. The signature of the personnel member who provided the counseling and the date signed.

evidence: Based on documentation review and interview, the administrator failed to ensure that each counseling session was documented in a resident's medical record to include the signature of the personnel member who provided the counseling and the date signed. Findings: 1. A review of R2's medical record revealed counseling sessions for March 6, 2023 and April 3, 2023. The counseling sessions did not include an electronic signature or signature of the personnel member who provided the counseling and the date signed. 2. In an interview, E1 reported E1 provided the counseling on the dates identified. E1 acknowledged the counseling sessions did not include the electronic signature or signature of the personnel member who provided the counseling and the date signed.

rule: C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 4. Training for a personnel member, other than a medical practitioner or registered nurse, in assistance in the self-administration of medication: a. Is provided by a medical practitioner or registered nurse or an individual trained by a medical practitioner or registered nurse; and b. Includes: i. A demonstration of the personnel member's skills and knowledge necessary to provide assistance in the self-administration of medication, ii. Identification of medication errors and medical emergencies related to medication that require emergency medical intervention, and iii. The process for notifying the appropriate entities when an emergency medical intervention is needed;

evidence: Based on record review and interview, the administrator failed to ensure training in the assistance in the self-administration of medication included a demonstration of the personnel member's skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors, and medical emergencies related to medication that required emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention was needed.

findings: 1. A review of E2 and E3's personnel records revealed no documentation of training in the assistance in the self-administration of medication. 2. In an interview, E1 reported E2 and E3 did complete training in the assistance in the self administration of medication. E1 reported the documentation should have been in the identified personnel records however the documentation could not be located. E1 acknowledged E2's, and E3's training did not include documentation of training in the assistance in the self-administration of medication as required.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

evidence: Based on documentation review and interview, the administrator failed to ensure a disaster drill for employees was conducted on each shift at least every three months and documented.

findings: 1. A request for the facility's disaster drills conducted during the past 12 months revealed no drills were available for review. 2. In an interview, E1 reported E1 reviewed the disaster drill policy and procedure with employees at the time of hire. E1 acknowledged the disaster drills were not conducted on each shift at least every three months and documented.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 5. An evacuation drill for employees and residents on the premises is conducted at least once every six months on each shift;

evidence: Based on documentation review and interview, the administrator failed to ensure an evacuation drill for employees and residents on the premises was conducted at least once every six months on each shift.

findings: 1. A review of the facility's evacuation drills revealed no evacuation drills were available for review. 2. In an interview E1 reported the facility had not conducted evacuation drills for employees and residents. E1 acknowledged the administrator failed to ensure an evacuation drill for employees and residents on the premises was conducted at least once every six months on each shift.


state: AZ

facility_name: AVERY'S HOUSE, LLC

summary: Complaint - 2/12/2025

raw_content: An on-site investigation of complaints 00105718 and 00108488 was conducted on February 12, 2025, and the following deficiencies were cited:

inspection_type: Complaint

rule: R9-10-703.C.1.f. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: f. Cover implementation of the requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;

evidence: Based on observation, documentation review and record review, the administrator failed to ensure policies and procedures were implemented to protect the health and safety of a resident that cover implementation of the requirements in A.R.S. §§ 36-425.03.

findings: 1. The Compliance Officer observed E4 working on-site. 2. A review of the facility’s policies and procedures revealed a policy titled “Job Descriptions“ dated November 1, 2021. The policy stated “Position: Behavioral Health Technician…Minimum qualifications…Current and valid Arizona Fingerprint Card.” 3. A review of E4’s (hired as a behavioral health technician) personnel record revealed a print out from the Department of Public Safety’s website. The document included a fingerprint clearance card application number for E4, however, the document stated “Status In process”. 4. A review of the AZDPS Fingerprint Clearance Status website revealed E4's fingerprint clearance card application was received by AZDPS on September 10, 2024, however the status was "In Process". 5. In an interview, E1 reported to not be sure of the current status of E4’s fingerprint clearance card. 6. In an exit interview, the findings were reviewed with E1, E2, and E3, and further documentation or comment was not provided.


summary: Complaint - 9/5/2024

raw_content: An on-site investigation of complaint AZ00215867 was conducted on September 5, 2024 and the following deficiency was cited :

rule: G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a self-injury or has an accident that requires immediate intervention by an emergency medical services provider.

evidence: Based on record review, documentation review and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicted a self-injury requiring immediate intervention by an emergency medical services provider. The deficient practice posed a risk as the Department was unable to determine if there was an immediate health and safety risk to other residents admitted into the facility.

findings: 1. A review of R1' s medical record revealed an incident report of a medical overdose by R1 on September 1, 2024. The report stated "At med pass, [R1] was given [R1] seroquel and [R1] took the bottle, emptied it into [R1] mouth, and swallowed 13 or 14 tablets." The report indicated E4 contacted 911 and poison control, and R1 was transported and admitted to the hospital. 2. A review of Department documentation revealed documentation to demonstrate BH7513 provided written notification to the Department of R1's self-injury was not available for review. 3. In an interview, E1 reported R1 was receiving assistance in the self-administration of medication during the aforementioned incident by E4. E1 reported E4 opened the medication bottle of Seroquel 100 mg and handed it to R1 to complete the assistance in the self-administration of medication. E1 reported R1 reported the overdose was a suicide attempt.

rule: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

evidence: Based on record review and interview, the administrator failed to ensure a resident did not have access to any materials, furnishings, or equipment or participate in any activity or treatment to present a threat to the resident's health or safety based on the resident's personal history. The deficient practice posed a risk as R1 had access to administer medication while admitted into a behavioral health residential facility in contradiction with their personal history.

findings: 1. A review of R1's medical record revealed an incident report of a medical overdose by R1 on September 1, 2024. The report stated "At med pass, [R1] was given [R1] seroquel and [R1] took the bottle, emptied it into [R1] mouth, and swallowed 13 or 14 tablets." The report indicated E4 contacted 911 and poison control, and R1 was transported and admitted to the hospital. 2. A review of R1's medical record revealed a medication administration record (MAR) for September 2024. The MAR indicated E5 provided assistance in the self-administration of medication for Seroquel 100 mg on September 1, 2024. 3. A review of R1's medical record revealed a behavioral health assessment dated in 2024. The assessment stated R1 is diagnosed with "bipolar disorder", had "3-4 attempts" of suicide, and had "tried to overdose with Benadryl." 4. In an interview, E1 reported R1 was receiving assistance in the self-administration of medication during the aforementioned incident by E4. E1 reported E4 opened the medication bottle of Seroquel 100 mg and handed it to R1 to complete the assistance in the self-administration of medication.


summary: Complaint - 8/30/2024

raw_content: An on-site investigation of complaint AZ00215293 was conducted on August 30, 2024 and no deficiencies were cited :


summary: Complaint - 7/10/2024

raw_content: An on-site investigation of complaint AZ00212839 was conducted on June 10, 2024 and no deficiencies were cited :


summary: Complaint - 8/31/2023

raw_content: An on-site investigation of complaint AZ00199034 and AZ00194884 was conducted on August 31, 2023, and the following deficiencies were cited :

rule: K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence that includes the: a. Name of a resident absent without authorization, b. Name of the individual to whom the report required in subsection (K)(7) was submitted, and c. Date of the report; and

evidence: Based on documentation review and interview, the administrator failed to maintain a log of unauthorized absences that included the name of a resident absent without authorization, the name of the individual to whom the report required in subsection (K)(7) was submitted, and the date of the report.

findings: 1. A review of facility incident reports revealed three resident elopements on July 18, 2023, and two resident elopements on July 23, 2023. A review of facility documentation revealed no log of unauthorized absences was available for review. 2. In documentation review, a facility policy, titled, "Discharge Against Medical Advice (AMA) and (AWOL), page 81, documented, "...An AWOL log will be maintained by the Clinical Director of all clients leaving AWOL, this log shall be reviewed as a part of the quality management program. The log must contain a list of all unauthorized absences for at least 12 months after the date of a clients absence that includes the residences name, to whom the report was submitted, the date of the report the evaluation and any action that was taken because of the unauthorized absence." 3. During an interview, E1, E2, and E3 reported R1, R2, R3, and R4 left the facility without authorization in July 2023. E1 reported a log of unauthorized absences had not been maintained by the administrator.

evidence: Based on record review, and interview, for one of two personnel members reviewed, the administrator failed to ensure the personnel members' skills and knowledge were verified and documented before the personnel member provided behavioral health services. The deficient practice posed a health risk to residents if a personnel's skills and knowledge were not verified.

findings: 1. In record review, the personnel record for E6 (hired November 7, 2022, as a Behavioral Health Technician) included documentation of the verification of skills and knowledge dated March 24, 2023. 2. During an interview, E1 reported E6 was hired on November 7, 2022; however, the documentation of E4's skills and knowledge was not completed until March 24, 2023, and before E4 provided behavioral health services, as required.

rule: E. An administrator shall ensure that: 2. A personnel member completes orientation before providing behavioral health services or physical health services;

evidence: Based on record review, and interview, for one of two personnel records reviewed, the administrator failed to ensure a personnel member completed orientation before providing behavioral health services. The deficient practice posed a risk if an employee was not provided orientation before providing behavioral health services to residents.

findings: R9-10-101(155) "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. In record review, the personnel record for E6 (hired November 7, 2022, as a Behavioral Health Technician), did not include documentation of orientation. 2. During an interview, the personnel record was reviewed with E1, who acknowledged E6's personnel record did not include documentation of completed orientation before providing behavioral and/or physical health services.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: e. The individual's compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;

evidence: Based on record review and interview, for two of two personnel records reviewed, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of compliance with the requirements in A.R.S. \'a7 36-425.03(A)(E), The deficient practice posed a risk if an employee was a danger to a vulnerable population.

findings: A.R.S. \'a7 36-425.03(E) states "Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction." 1. In record review, E6's personnel record (hired November 7 2022) as a behavioral health technician (BHT) included a valid fingerprint clearance card; however, documentation of compliance with A.R.S. \'a7 36-425.03(E) was not provided for review. 2. In record review, E7's personnel record (hired September 2, 2022) as a behavioral health technician (BHT) included a valid fingerprint clearance card; however, documentation of compliance with A.R.S. \'a7 36-425.03(E) was not provided for review. 3. During an interview, E1 acknowledged the personnel records did not include the required documentation of compliance with A.R.S. \'a7 36-425.03(E).


summary: Compliance (Annual) - 8/8/2023

raw_content: Based on Arizona Revised Statutes \'a7 36-424(B) and Arizona Administrative Code R9-10-109(E), the Department may accept an accreditation report in lieu of an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from the Joint Commission, valid through through September 22, 2025. If the health care institution's accreditation report is not valid for the entire licensure period, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.

inspection_type: Compliance (Annual)


facility_name: HUMAN CARE SERVICES

summary: Complaint - 9/16/2025

raw_content: No deficiencies were found during the on-site  investigation of complaint 00144934 conducted on September 16, 2025.


summary: Compliance (Annual) - 6/19/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on June 19, 2025:

rule: R9-10-706.G.3.a. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: a. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member, to include documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties.

findings: 1. A review of the facility policies and procedures dated in 2023, under a section titled "Employees and Volunteers Qualifications" stated, "A. In order to provide adequate care to our residents, it is required that each employee and volunteer be knowledgeable of their job description and duties. B. Each employee meets the qualifications, required skills, education, knowledge, and experience. Employment requirements: -Full name, -date of birth, -Current address and phone number, -Date of hire and termination date at the end of employment, - Work experience and references, specific to the position applying for as outlined below." 2. A job description for a Behavioral Health Technician (BHT) stated the following, "Minimum Qualifications: Must be 21 years old to work at this facility. An associate's degree and at least two years of full time Behavioral health and personal care work experience, or a high school diploma or high school equivalency diploma (GED) and has at least four years of behavioral health and personal care work experience; or a registered nurse, or a licensed practical nurse (LPN) or certified nursing assistant (CAN) with at least two years of full time behavioral health and personal care experience. Must also have a valid Arizona state driver’s license. Must have experience in dealing with residents with Behavioral health disorder diagnosis and co-occurring disorders; understands and be able to identify medications commonly prescribed for mental disorders. Experience in providing resident support/interventions focusing on behavioral health disorders; active management and personal care of residents with Behavioral health issues. Understanding of services needed for residents with Behavioral health issues." 3. A review of E3's personnel record (hired in 2025 as a BHT) revealed no evidence of a completed job application, which included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties. 4. In an exit interview, the findings were reviewed with E1, who requested to obtain E3's job application. However, no documentation was provided. This is a repeated deficiency from a complaint investigation conducted on August 26, 2024.

rule: R9-10-706.G.3.b. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: b. The individual's education and experience applicable to the individual's job duties;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's education and experience applicable to the individual's job duties. The deficient practice posed a health and safety risk to residents if personnel were not qualified for the position hired for.

findings: 1. A review of facility policies and procedures dated in 2023, under the section titled "Employees and Volunteers Qualifications" stated, "The hiring person or manager will ensure, check and document that the employee or volunteer providing physical health services or behavioral health service have the required skills and knowledge before providing any services. Qualifications Behavioral Health Technician (BHT). Minimum Qualifications: Must be 21 years old to work at this facility. An associate's degree and at least two years of full time Behavioral health and personal care work experience; or a high school diploma or high school equivalency diploma (GED) and has at least four years of behavioral health and personal care work experience; or a registered nurse, or a licensed practical nurse (LPN) or certified nursing assistant (CAN) with at least two years of full time behavioral health and personal care experience. Must also have a valid Arizona state driver’s license. Must have experience in dealing with residents with Behavioral health disorder diagnosis and co-occurring disorders; understands and be able to identify medications commonly prescribed for mental disorders. Experience in providing resident support/interventions focusing on behavioral health disorders; active management and personal care of residents with Behavioral health issues. Understanding of services needed for residents with Behavioral health issues." 2. A review of E2's personnel record (hired in 2024) revealed E2 had no behavioral health experience as required by the facility's employee qualifications for a BHT. E2's personnel record revealed a resume which included experience as a food server and lifeguard. 3. In an exit interview, the findings were reviewed with E1, who reported being aware E2 did not have the minimum qualification to have been hired as a BHT and reported E2 had "quit" in June 2025.

rule: R9-10-706.G.3.f. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: f. The individual ' s compliance with the requirements in A.R.S. § 8-804, if applicable;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member, employee, volunteer, or student to include documentation of the individual's compliance with the requirements in A.R.S. § 8-804. The deficient practice posed a safety risk to residents under the age of 18 if personnel had not passed a Department of Child Safety (DCS) registry check as required.

findings: 1. A review of Department documentation revealed BH7917 was licensed in 2022 as a behavioral health residential facility to provide services to residents under 18 years of age. 2. A review of E2's personnel record (hired in 2024) revealed no evidence of a DCS central registry background check, which was required as per R9-10-706.G.3.f. 3. A review of E3's personnel record (hired in 2025) revealed no evidence of a DCS central registry background check, which was required as per R9-10-706.G.3.f. 4. In an exit interview, the findings were reviewed with E1, who reported being aware E2 and E3 had not completed a DCS registry check as per R9-10-706.G.3.f.

rule: R9-10-707.A.13.a. Admission; Assessment A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis: a. Before or within seven calendar days after the resident's admission, and

evidence: Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's admission. The deficient practice posed a TB exposure risk to residents.

findings: 1. A review of R1's medical record (admitted in 2025) revealed no evidence of freedom from infectious TB before or within seven calendar days after R1's admission. 2. In an exit interview, the findings were reviewed with E1, who reported not having received R1's TB test results from the last facility R1 was at.


summary: Complaint - 12/18/2024

raw_content: An on-site investigation of complaint AZ00220513 was conducted on December 18, 2024 and no deficiencies were cited.


summary: Complaint - 10/15/2024

raw_content: An on-site investigation of complaint AZ00215255 was conducted on October 15, 2024 and no deficiency was cited :


summary: Complaint - 9/19/2024

raw_content: An on-site investigation of complaint AZ00215303 was conducted on September 19, 2024 and no deficiency was cited.


summary: Complaint - 8/26/2024

raw_content: An on-site investigation of complaint AZ00215077 was conducted on August 26, 2024, and the following deficiencies were cited :

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: a. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel members to include documentation of the individual's skills and knowledge, for one former behavioral health technician (BHT) sampled The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

findings: 1. A review of the facility's policies and procedure revealed a policy titled "Personnel Records." dated August 1, 2022. The policy stated "...t) Administrator will do a pre-employment checklist for all new hires including skills and knowledge applicable to each individual job duties." 2. A review of E4's (hired as a BHT) personnel record revealed documentation to demonstrate E4's skills and knowledge were verified and documented was not available for review. 3. In an interview, E1 reported E4's skills and knowledge were verified, however, E1 could not locate the documentation. E1 acknowledged documentation to demonstrate E4's skills and knowledge were verified and documented was not available for review.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: c. The individual's completed orientation and in-service education as required by policies and procedures;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed orientation as required by policies and procedures, for one former behavioral health technician (BHT) sampled. The deficient practice posed a risk if E4 was unable to meet the needs of the residents.

findings: 1. Arizona Administrative Code (A.A.C.) R9-10-101(155) states "Orientation" means "the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution." 2. A review of the facility's policies and procedures revealed a policy titled "New Hire Orientation" dated August 1, 2022. The policy stated "Every new hire will be given a new hire orientation to the philosophy, policies and procedures, vision within the company. The new hire orientation shall be completed before each personnel member provides service to a resident." 3. A review of E4's personnel record revealed documentation of E4's completed orientation was not available for review. 4. In an interview, E1 reported E4 had completed orientation, however, E1 could not locate the document. E1 acknowledged documentation of E4's completed orientation was not available for review.

rule: 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 with any other resident that may present a threat to the resident's health or safety, based on the other resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, and personal history.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident did not share any space, verbally or physically interact with any resident who may present a threat to the resident's health and safety based on the other resident's documented diagnosis, treatment needs, and personal history.

findings: 1. A review of facility documentation revealed an incident report dated June 7, 2024. The incident report stated "Client [R1] woke up and went downstairs and sat outside, client's 1:1 [E5] followed in an attempt to have a conversation with [R1] to ensure [R1] was safe. Client ignored staff while [E5] attempted to talk to [R1]. Client [R1] then walked over the the trash can and sat on top of it and smiled. [R1's] 1:1 [E5] made another attempt to talk with the client but client responded, "leave me alone I am going to AWOL." Staff reminded the client of the importance of trying to complete [R1's] treatment and was able to deescalate client and had [R1] return inside the facility....While staff was still talking to client [R1], client [R2] came to the back door and said "how come i don't get a blanket" and proceeded to walk outside. Staff followed and saw [R2] was attempted to jump over the back wall. Staff engaged with client [R2] in an attempt to deescalate...While going into the facility client [R2] walked up to staff and grabbed an item out of staff's pocket and ran upstairs to [R2's] room. Staff followed client in an attempt to retrieve the stolen item but client refused to return it. Client [R1] then came upstairs and overheard the conversation between staff and client [R2] and tried to intervene. Staff redirected [R1] and had [R1] return to [R1's] room. While working with client [R2], client [R1] ran out [R1's] room and kicked client [R2]. both client were separated and deescalated. While clients were downstairs eating breakfast client [R2] threw an apple and hit client [R1]. Client [R1] then ran up to client [R2] and pulled [R2's] hair. Clients exchanged foul language toward each others, staff intervened shortly after. Client [R2] then grabbed the facility phone, ran outside and called the police...Client informed the AMR staff that [R2] was feeling pain in [R2's] shoulder and asked to go to the hospital. Client was transported by AMR to Chandler Regional hospital. Client was assessed at the hospital and was medically cleared DCS hotline [O1] was contacted and informed of the situation at hand." 2. A review of R1's medical record revealed a treatment plan dated in 2024. The document stated "IDENTIFIED NEED AND SPECIFIC OBJECTIVES Goal #1 NEED: Improve anger management skills OBJ: [R1] will increase [R1's] awareness of anger expression patterns. [R1] will learn to identify triggers and causes for anger...CURRENT MEASURE June 17, 2024, Physical fight with peer. Profanity towards staff and peers..." 3. A review of R1's medical record revealed a behavioral health assessment dated in 2024. The document stated "Presenting issues:...[R1] has a history of being verbally and physically aggressive with family members and staff at previous DDD group home. 4. In an interview, E1 reported R1 is on a one on one, where a staff member accompanies R1 everywhere R1 goes. E1 reported residents eat at the same table with R1, and do counseling groups with R1 present. E1 reported a staff member sits next to R1 in both instances. E1 acknowledged the administrator failed to ensure that a resident does not share a space with another resident that may present a threat to the resident's health or safety, based on the other resident's documented diagnoses, treatment needs, and personal history.

rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: c. Contains a door that opens into a hallway, common area, or outdoors;

evidence: Based on observation and interview, the administrator failed to ensure a resident bedroom contained a door. The deficient practice posed a risk if residents were unable to ensure their privacy.

findings: 1. The Compliance Officer observed five bedrooms in the facility: -A master bedroom shared by R1 and R3; -A master bedroom shared by R4 and R5; and -Three bedrooms occupied by three separate residents. However, the bedrooms did not contain doors. 2. In an interview, E1 reported the bedroom doors had been removed for safety concerns. E1 acknowledged the bedrooms did not contain doors.


summary: Complaint - 8/13/2024

raw_content: An on-site investigation of complaint AZ00214488 and AZ00214438 was conducted on August 13, 2024, and the following deficiencies were cited :

rule: A. An administrator shall ensure that: 1. A resident is admitted based upon: b. The resident's behavioral health issue and treatment needs are within the behavioral health residential facility's scope of services;

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a resident's admission based on a resident's behavioral health issue, and treatment needs were within the facility's scope of services for one of two residents sampled. The deficient practice posed a risk to the health and safety of resident if the facility was unable to meet the treatment needs of residents.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Scope of Services" dated August 1, 2022. The policy stated "Admission Criteria...Diagnosed with mental disorder...Enrolled with a mental health agency...Able to actively participate in treatment and developing his/her care...Not a danger to self or others..." 2. A review of R1's medical record revealed a behavioral health assessement dated in 2024. The assessment stated "History of Presenting Issues: [R1] was admitted at [facility name] on [date] for passive suicidal ideation and substance abuse. [R1] admitted to self-harming via cutting [R1's] arms stating the last time was a couple weeks ago...SI/Self Harm (Suicidal ideation/Self-Harm) [R1] with DTO behaviors to include self-injury..." 3. In an interview, E1 reported R1 is not currently a danger to self. E1 acknowledged R1's behavioral health issues were not consistent within the behavioral health residential facility's scope of services.

rule: A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently receives: b. Continuous protective oversight;

evidence: Based on documentation review and interview, the administrator failed to ensure if a behavioral health residential facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk to health and safety of residents, who required continuous protective oversight. Finding include: 1. A review of facility documentation, revealed a document titled "Incident Report" dated August 11, 2024. The document stated "Client [R2] informed staff that [R2] was touched on [R2's] inner thigh area, and private spot by client [R1] during group activity in the living room, as they sat together as staff was not looking. Client [R2] informed staff that [R2] and client [R1] were in former a relationship, but [R2] no longer wants to be in the relationship. Client [R2] stated [R2] was unsure on how to end the relationship, so wants staff to intervene. Staff [E2] spoke with each client individually, and both client stated they consented to touching on the inner thighs. Staff advised both clients about the inappropriateness of their relationship, and that they will not be able to have that type of relationship. Staff further advised that it's best if they are kept separated. Both clients understood and agreed to stay separated..." 2. In an interview, E1 reported the incident occurred in the living room area, and R1 and R2 were sitting on the couch next to each other. E1 reported multiple staff work each shift, and provide continuous protective oversight, however, the incident occurred when staff were not facing the residents. E1 acknowledged the residents did not receive continuous protective oversight.


summary: Compliance (Annual) - 6/4/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on June 4, 2024:

rule: An administrator shall ensure that: 2. A documented report is submitted to the governing authority that includes: a. An identification of each concern about the delivery of services related to resident care, and b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care;

evidence: Based on documentation review and interview, the administrator failed to ensure a documented reported was submitted to the governing authority to include an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care.

findings: 1. A review of facility documentation revealed a policy and procedure manual dated in 2023 under section "Quality Management" stated, "In order to provide quality and safe services to the facility residents, the administrator shall ensure that: Facility personnel will document and evaluate incidents at the facility to ensure adequate quality of services provided. Facility may use a survey tool (Quality of Service Month Recording Form) to help in identifying and collecting information. Data and reports collected are used to identify a concern about the delivery of services related to resident care and are available as per procedure below. The facility governing authority reviews and evaluates the effectiveness of the quality management program at least once every 12 months." 2. A review of facility documentation revealed the facility had no documentation of quality management tracking or reports, per the facility policy and procedures. 3. In an interview with E1, acknowledged the facility had no documentation of quality management tracking or reports, per the facility policy and procedures.

rule: A. An administrator shall ensure that: 6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission;

evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission, for one of two residents sampled. The deficient practice posed a risk of not meeting a resident's needs if no medical history and physical examination or nursing assessment were completed to assess a resident's needs prior to treatment.

findings: 1. A review of R2's medical record (admitted April 2024) revealed a document titled "Nursing Assessment" dated on April 16, 2024. Based on R2's date of admission, the nursing assessment was not dated within 30 calendar days before admission or within 72 hours after admission. 2. In an interview, E1 acknowledged R2's medical record revealed a registered nurse had not performed a nursing assessment within 30 calendar days before R2's admission or within 72 hours after R2's admission.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, a registered dietitian or director of food services shall ensure that: 3. Meals and snacks provided by the behavioral health residential facility are served according to posted menus;

evidence: Based on documentation review and interview, the registered dietician or director of food services failed to ensure meals provided by the behavioral health residential facility were served according to posted menus.

findings: 1. A review of facility documentation revealed a posted menu dated in June 2024. The menu revealed for Tuesday June 4, 2024, breakfast would include the following: Banana bread or cereal, applesauce, and orange juice. 2. In an interview, R1 reported R1's breakfast consisted of oatmeal and cereal. 3. A review of facility documentation revealed the lunch menu for the previous day June 3, 2024 consisted of pork chop with roll, baked potato with sour cream and butter, green beans and applesauce. 4. In an interview, R1 reported R1's lunch was a beef patty, and no potato or green beans as indicated on the menu. 5. In an interview, E1 acknowledged the meal provided for lunch on June 3, 2024 and the breakfast served on June 4, 2024 was not served according to the posted menu.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 5. An evacuation drill for employees and residents on the premises is conducted at least once every six months on each shift;

evidence: Based on documentation review and interview, the administrator failed to ensure an evacuation drill for employees and residents on the premises was conducted at least once every six months on each shift. The deficient practice posed a risk if the employees were not able to implement the disaster plan in the case of the need to evacuate in an emergency.

findings: 1. A review of the facility documentation revealed no evidence evacuation drills were conducted for employees and residents at least once every six months on each shift for the past 12 months. 2. In an interview, E1 acknowledged the facility did not have documentation evacuation drills were conducted for employees and residents at least once every six months on each shift for the past 12 months.


summary: Complaint - 2/8/2024

raw_content: An on-site investigation of complaint AZ00206159 was conducted on February 8, 2024 and the following deficiency was cited :

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 2. Is completed: b. Before the resident receives physical health services or behavioral health services or within 48 hours after the assessment is completed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was completed, before physical health or behavioral health services was provided, for one of three residents sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements before treatment was initiated.

findings: 1. A review of R3's medical record revealed an intake assessment for R3 was completed on November 28, 2023. However, the treatment plan (completed December 2, 2023) was not completed before physical health services or behavioral health services were provided for R3. 2. A review of R3's medication administration record (MAR) for the month of November, 2023, revealed R3 received assistance in the self-administration of medication beginning on November 28, 2023 for the following medications: Aripiprazole 10 mg and Hydroxizine 2 mg. 3. In an interview, E1 acknowledged a treatment plan for R3 was not completed before R3 was provided physical health services or behavioral health services.


summary: Complaint - 10/4/2023

raw_content: An on-site investigation of complaints AZ00201428, AZ00201430, AZ00201427, AZ00201356, AZ00201359, AZ00201360, AZ00201358, and AZ00200914 was conducted on October 04, 2023, and the following deficiencies were cited :

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

evidence: Based on observation, and interview, the administrator failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents.

findings: 1. Upon arrival to the facility, the Compliance Officer observed a broken window in a resident bedroom, which had not been repaired since a rule violation was cited on September 9, 2023. 2. In an interview, E1 acknowledged the broken window in one of the resident's bedrooms. E1 reported the window would be fixed but could not provide an exact or estimated date of completion as an insurance claim was involved and reported the repair could take up to three months from the time the claim was filed. This Rule was cited on September 5, 2023. A letter sent to the facility, dated September 20, 2023, stated "...the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel. Additionally, the Department urges correction of all deficiencies at the earliest possible date."


summary: Complaint - 9/5/2023

raw_content: An on-site investigation of complaint AZ00200092 and AZ00199850 was conducted on September 5, 2023 and the following deficiencies were cited :

rule: G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a self-injury or has an accident that requires immediate intervention by an emergency medical services provider.

evidence: Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicts a self-injury that requires immediate intervention by an emergency medical services provider. The deficient practice posed a risk as the Department was not notified to determine if there was an immediate risk to resident health and safety.

findings: 1. A review of Department documentation did not reveal evidence the Department was notified by BH7917 of a resident's self-injury requiring immediate intervention by an emergency medical services provider within two days. 2. A review of the facility's documentation, revealed a document titled, "Incident Report," which detailed how R1, R2, and R3 self-injured on August 27, 2023. 3. In an interview, E1 acknowledged written notification to the Department of the incident was not provided within two days as required. 4. In an interview, E1 reported R1's, R2's, and R3's self-injuries were "only superficial" and did not require medical attention. However, documentation to indicate otherwise, was not available for review. This is a repeat deficiency from the complaint inspection conducted on July 13, 2023.

rule: A. An administrator shall ensure that a discharge plan for a resident is: 1. Developed that: a. Identifies any specific needs of the resident after discharge, b. Is completed before discharge occurs, and c. Includes a description of the level of care that may meet the resident's assessed and anticipated needs after discharge;

evidence: Based on record review and interview, the administrator failed to ensure that a discharge plan for a resident is developed that identifies and specific needs of the resident after discharge; is completed before discharge occurs and includes a description of the level of care that may meet the resident's assessed and anticipated needs after discharge for four of four residents sampled.

findings: 1. A review of R1's, R2, and R3's medical records, did not reveal documented evidence of a discharge plan for R1, R2, and R3. Further review of the facility's documentation, revealed on August 27, 2023, R1, R2, and R3, were transported to Banner Cardon's Children's Hospital, where after being assessed, it was recommended R1, R2, and R3 be admitted in-patient to a behavioral health facility, Mind 24-7. 2. A review of R4's medical record did not reveal documented evidence of a discharge plan. Further review of the facility's documentation, revealed on August 25, 2023, R4 was discharged to Maricopa P.D. due to R4's out-of control, assaultive behavior, which R4 was being charged for. Since the Pinal County Youth Justice Center would not take in R4, Department of Child Services intervened and took custody of R4. 3. In an interview, E1 acknowledged R1's, R2's, R3's, and R4's medical records did not reveal documented evidence of discharge plans for R1, R2, R3, and R4.

rule: D. An administrator shall ensure that there is a documented discharge order by a medical practitioner or behavioral health professional before a resident is discharged unless the resident leaves the behavioral health residential facility against a medical practitioner's or behavioral health professional's advice.

evidence: Based on record review and interview, the administrator failed to ensure there was a documented discharge order by a medical practitioner or behavioral health professional before a resident was discharged, unless the resident leaves the behavioral health residential facility against a medical practitioner's or behavioral health professional's advice, for four of four residents sampled. The deficient practice posed a risk if the discharge order had not been documented by a medical practitioner or behavioral health professional.

findings: 1. A review of R1's, R2's, R3's, and R4's medical records did not reveal evidence of a discharge order by a medical practitioner or behavioral health professional before a resident was discharged. 2. In an interview, E1 acknowledged R1's, R2's, R3's, and R4's medical records did not reveal evidence of a discharge order by a medical practitioner or behavioral health professional before a resident was discharged.

rule: G. An administrator shall ensure that a discharge summary for a resident: 2. Includes: a. The following information authenticated by a medical practitioner or a behavioral health professional: i. The resident's presenting issue and other physical health and behavioral health issues identified in the resident's treatment plan; ii. A summary of the treatment provided to the resident; iii. The resident's progress in meeting treatment goals, including treatment goals that were and were not achieved; and iv. The name, dosage, and frequency of each medication ordered for the resident by a medical practitioner at the behavioral health residential facility at the time of the resident's discharge;

evidence: Based on record review and interview, the administrator failed to ensure a discharge summary for a resident included the following information authenticated by a medical practitioner or behavioral health professional (BHP): The resident's presenting issue and other physical health and behavioral health issues identified in the resident's treatment plan; a summary of the treatment provided to the resident; the resident's progress in meeting treatment goals, including treatment goals that were and were not achieved; and the name, dosage, and frequency of each medication ordered for the resident by a medical practitioner at the behavioral health residential facility at the time of the resident's discharge.

findings: 1. A review of R1's, R2's, R3's and R4's medical records did not reveal evidence of a discharge summary which included the following information authenticated by a medical practitioner or behavioral health professional: -The resident's presenting issue and other physical health and behavioral health issues identified in the resident's treatment plan; -A summary of treatment provided to residents; -The resident's progress in meeting treatment goals, including treatment goals that were and were not achieved; and -The name, dosage, and frequency of each medication ordered for the resident by a medical practitioner at the behavioral health residential facility at the time of the resident's discharge. 2. In an interview, E1 acknowledged R1's, R2's, R3's, and R4's medical records did not reveal evidence of discharge summaries for each resident, and according to R9-10-709.G.2.a.i-iv.

rule: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

evidence: Based on, documentation review, record review, and interview, the administrator failed to ensure a resident did not use or have access to any materials, or participate in any activity to present a threat to the resident's health or safety based on the resident's documented diagnosis, or personal history for three of four residents sampled. The deficient practice posed a direct risk to the health and safety of residents.

findings: 1. A review of the facility's documentation, revealed a document titled "Incident Report" written August 27, 2023. The incident report detailed how R1, R2, and R3 self-injured with items including glass, a cuticle trimming tool, and a piece of plastic. 2. In an interview, E1 acknowledged the items with which R1, R2, and R3, attempted self-harm. El reported residents are allowed to use beauty tools. However, residents must be supervised while using any tool that could cause harm. This is a repeat deficiency from a compliance and complaint inspection conducted on May 11, 2023.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: a. Maintained in a condition that allows the premises and equipment to be used for the original purpose of the premises and equipment; b. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

evidence: Based on observation and interview, the administrator failed to ensure the premises and equipment were maintained in a condition that allowed the premises and equipment to be used for the original purpose of the premises and equipment, and were free from a condition or situation that may cause a resident or other individual to suffer physical injury.

findings: 1. During a facility tour, the Compliance Officer observed, in a resident bedroom, a window, boarded up with plywood. 2. During a facility tour, the Compliance Officer observed, in a resident bathroom, a cabinet door, under the sink, which was broken and loosely attached. 3. In an interview, E1 acknowledged boarded up window and the broken cabinet door. E1 reported the window had broken during a storm days ago and had made arrangements to get it fixed.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 6. Garbage and refuse are: a. Stored in covered containers lined with plastic bags, and

evidence: Based on observation and interview, the administrator failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. The deficient practice posed a risk to the health and safety of residents, as well as, infection control.

findings: 1. During the facility tour, the Compliance Officer observed two uncovered but lined trash containers, containing refuse in two of the facility's bathrooms. 2. In an interview, E1 acknowledged the garbage container, which contained refuse in two of the facility's bathrooms were not covered.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 12. Soiled linen and soiled clothing stored by the behavioral health residential facility are maintained separate from clean linen and clothing and stored in closed containers away from food storage, kitchen, and dining areas;

evidence: Based on observation and interview, the administrator failed to ensure soiled linen and soiled clothing was maintained and stored in closed containers.

findings: 1. During a facility tour, the Compliance Officer observed various soiled clothing on the floor in two of the facility's bedrooms, occupied by residents. 2. In an interview, E1 acknowledged soiled linens were not maintained and stored in closed containers.


summary: Complaint - 7/13/2023

raw_content: An on-site investigation of complaints AZ00196398 and AZ00196464, was conducted on July 13, 2023 and the following deficiencies were cited :

evidence: Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicts a self-injury that requires immediate intervention by an emergency medical services provider.

findings: 1. A review of Department documentation, revealing evidence the Department was notified by BH7917 of a resident's self-injury requiring immediate intervention by an emergency medical services provider was not available for review. 2. A review of documents titled, "Incident Report," revealed a report dated June 12, 2023, which stated R1 had left the facility without authorization, and also described a self-injury incident involving R1. 3. In an interview, E1 acknowledged written notification to the Department of the incident was not provided within two days as required. 4. In an interview, E1 reported R1 did not need medical attention for R1's self-harm. However, documentation to prove otherwise was not available for review.


summary: Complaint - 6/7/2023

raw_content: An on-site investigation of complaints AZ00195365, AZ00196054, AZ00196264, and AZ00196053 was conducted on June 7, 2023 and no deficiencies were cited :


summary: Complaint;Compliance (Annual) - 5/11/2023

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00191147 and AZ00189647, conducted on May 11, 2023:

inspection_type: Complaint;Compliance (Annual)

rule: C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: e. Cover cardiopulmonary resuscitation training including: i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the individual's ability to perform cardiopulmonary resuscitation; ii. The qualifications for an individual to provide cardiopulmonary resuscitation training; iii. The time-frame for renewal of cardiopulmonary resuscitation training; and iv. The documentation that verifies that the individual has received cardiopulmonary resuscitation training;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure policies and procedures were implemented to protect the health and safety of a resident that covered cardiopulmonary resuscitation (CPR) training, which included a demonstration of the individual's ability to perform CPR, for one of five personnel records sampled. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of E2's personnel record, revealed a CPR and First Aid card. However, the card expired on February 4, 2023 2. In an interview, E1 acknowledged E2's personnel record contained an expired CPR and First Aid card.

rule: C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: f. Cover dispensing medication, administering medication, assistance in the self-administration of medication, and disposing of medication, including provisions for inventory control and preventing diversion of controlled substances;

evidence: Based on documentation review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover assistance in the self-administration of medication and preventing diversion of controlled substances. The deficient practice posed a risk to the health and safety of residents if the health care institution failed to implement policies and procedures to ensure residents were monitored while taking medications.

findings: 1. A review of the facility's policy and procedure, dated August, 2022, revealed a section titled "Assistance with Self-Administration of Medication," stated, "Authorized staff will assist only one resident at a time, other resident should not be in the same area during assistance with self-administration of medication. Administrator and RN shall monitor the staff members authorized to administer medication; to prevent narcotic diversion of controlled substance, inventory will be done on all medications." 2. In an interview, E1 reported the staff who provided assistance in the self-administration of medications, on January 24, 2023, was "distracted" by R2. As a result, R2 managed to get a hold of a bottle containing sixteen Oxcarbazepine 600 mg capsules, which in turn gave the pills to R1 and R2. 3. In an interview, E1 acknowledged neither the nurse or the administrator were present during assistance with self-administration of medications, as required by the facility's policies and procedures.

rule: B. An administrator shall ensure that: 2. A personnel member's skills and knowledge are verified and documented: a. Before the personnel member provides physical health services or behavioral health services, and b. According to policies and procedures; and

evidence: Based on record review, and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented before the personnel member provided physical health services or behavioral health services, and according to policies and procedures, for two of five personnel members sampled. The deficient practice posed a risk to the health and safety of residents if employee's skills and knowledge were not verified to provide services to meet the needs of residents.

findings: 1. A review of E1's personnel record (hired on October 1, 2023), revealed no documented evidence E1's skills and knowledge verification had been completed. 2. A review of R4's medical record, revealed a medication administration record (MAR) showing E1 had provided services in the assistance in the self-administration of medications to R4 on October 1-4, 2022. 3. A review of E2's personnel record (hired on October 28, 2022), revealed no documented evidence E2's skills and knowledge verification had been completed. 4. A review of R4's medical record, revealed a medication administration record (MAR) showing E2 had provided services in the assistance in the self-administration of medications to R4 on November 23-24, 2022. 5. In an interview, E1 acknowledged E1's and E2's skills and knowledge had not yet been verified since being hired. 6. In an interview, E1 acknowledged services have been provided to residents by E1 and E2 before E1's and E2's skills and knowledge was verified.

rule: E. An administrator shall ensure that: 2. A personnel member completes orientation before providing behavioral health services or physical health services;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member completed orientation before providing physical health or behavioral health services, for two of five personnel sampled. The deficient practice posed a risk if employees were not orientated to provide services to meet the needs of the residents.

findings: Pursuant to R9-10-101(155), "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of the facility's policy and procedure, titled "New Hire Orientation" dated in 2022, revealed the following: "The new hire orientation shall be completed before each personnel member provides service to a resident." 2. A review of E1's personnel record (hired on October 1, 2022), revealed no documented evidence E1's new hire orientation had been completed. 3. A review of R4's medical record, revealed a medication administration record (MAR) showing E1 had provided services in the assistance in the self-administration of medications to R4 on October 1-4, 2022. 4 A review of E2's personnel record (hired on October 28, 2022), revealed no documented evidence E2's new hire orientation had been completed. 5. A review of R4's medical record, revealed a medication administration record (MAR) showing E2 had provided services in the assistance in the self-administration of medications to R4 on November 23-24, 2022. 6. In an interview, E1 acknowledged E1's and E2's personnel file did not contain documented evidence E1' and E2's orientation had been completed.

evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission, for one of five residents sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1.

findings: 1. A review of R3's medical record, revealed a physical assessment dated October 28, 2022. R3's date of admission was December 4, 2022. R3's nursing assessment or medical history and physical examination was not dated within 30 calendar days before admission or within 72 hours after admission. 2. In an interview, E1 acknowledged R3's medical records did not include a nursing assessment or medical history and physical examination dated within 30 calendar days before admission or within 72 hours after admission.

rule: A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis: a. Before or within seven calendar days after the resident's admission, and b. As specified in R9-10-113.

evidence: Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's admission, for one of five residents sampled. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of R1's medical record (admitted on December 27, 2022), did not include documentation, R1 provided evidence of freedom from infectious TB before or within seven calendar days after R1's admission date. 2. In an interview, E1 acknowledged R1's medical record, did not include documentation R1 provided evidence of freedom from infectious TB before or within seven calendar days after R1's admission date.

evidence: Based on observation, documentation review, record review, and interview, the administrator failed to ensure a resident did not use or have access to any materials, or participate in any activity to present a threat to the resident's health or safety based on the resident's documented diagnosis, or personal history. The deficient practice posed a risk as residents were exposed to unprescribed medications, which put the resident's health and safety at risk.

findings: 1. A review of the facility's documentation, revealed a document titled "Human Care Services Incident Report" dated January 24, 2023. The report stated R3 and R5 appeared to be "under the influence," as staff questioned R3 and R5, it was discovered R3 and R5 had ingested eight unprescribed Oxcarbazepine 600 mg capsules each, given to R3 and R5 by R2, who had taken the pills during assistance with the self-administration of medication, without staff noticing. Both R3 and R5 were transported to the nearest emergency room location in Maricopa. 2. In an interview, E1 acknowledged R2, R3, and R5 all had access to materials (unprescribed medications) that presented a threat to the resident's health and safety.

rule: E. When medication is stored at a behavioral health residential facility, an administrator shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

evidence: Based on documentation review, and interview, the administrator failed to ensure medication stored at a behavioral health residential facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the health and safety of residents if medications were left unsecured and accessible to residents.

findings: 1. A review of the facility's policies and procedures dated in 2022, revealed a section titled "Storage of Medication." The policy stated, "Human Care Services Home Care shall follow Arizona Department of Health Services and the prescribing medication guidelines will be used on how all medications will be stored under a double lock system inaccessible to residents and other unauthorized individuals. Procedures: The medication area shall be secured at all times and never left unattended." 2. A review of the facility's documentation, revealed and incident report, detailing how R2, during assistance with self-administration of medication, had access to R2's medications and take a medication bottle containing 16 Oxcarbazepine 600 mg tablets, without the staff providing assistance in the self-administration of medication, becoming aware of the occurrence. 3. In an interview, E1 acknowledged staff did not follow proper procedure protocol when assisting with the self-administration of medication to residents.


facility_name: GLORIOUS CARE PROJECT LLC

summary: Complaint - 2/2/2026

raw_content: No deficiencies were found during the on-site investigation of complaint 00157533 conducted on February 2, 2026.


summary: Compliance (Annual) - 12/1/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on December 1, 2025.

rule: R9-10-113.A.2.a-f. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

evidence: Based on record review and interview, the administrator failed to implement tuberculosis (TB) infection control activities, which included baseline screening consisting of assessing risks of prior exposure to infectious TB, and determining if the individual had signs or symptoms of TB, for one of six personnel records sampled, and one of two resident records sampled. The deficient practice posed a health and safety risk if residents were exposed to TB.

findings: 1. A review of E4's personnel record revealed no documentation of assessing risks of prior exposure to infectious TB, and determining if the individual has signs or symptoms of TB. 2. A review of R2's medical record revealed no documentation of assessing risks of prior exposure to infectious TB, and determining if the individual has signs or symptoms of TB. 3. In an interview, E1 reported E1 was unable to locate documentation of assessing risks of prior exposure to infectious TB, and determining if the individual has signs or symptoms of TB within E4’s personnel record or E2’s resident record. 4. In an exit interview, the findings were reviewed with E1, and no additional comments or statements were provided regarding the findings.

rule: R9-10-718.C.6.b. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 6. Assistance in the self-administration of medication provided to a resident: b. Is documented in the resident's medical record.

evidence: Based on record review, observation, and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a health and safety risk if a resident were to experience a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of R1's medical record revealed a medication administration record (MAR) for November 2025. The MAR revealed the following medications were scheduled to be taken at 7:00 PM: -"Risperidone 1 mg tablet take 1 tablet by mouth daily at night for mood"; -"Trazodone 50 mg tablet take 1 tablet by mouth everyday at bedtime"; -"Oxcarbazepine 300 mg tablet cam take 2 tablets by mouth once daily in the evening for mood". 2. A review of R1's medical record revealed a medication administration record (MAR) for November 2025. The MAR revealed the following medications were scheduled to be taken at 7:00 AM: -"Oxcarbazepine 300 mg tablet cam take 1 tablet by mouth once daily in the morning". 3. A review of R1’s medical record revealed no MAR available to review for December 2025. 4. The Compliance Officer observed the medications scheduled for November 30, 2025, at 7:00 PM, and December 1, 2025, at 7:00 AM were not documented in R1's MAR while on-site on December 1, 2025, at 9:23 AM. 5. In an interview, E1 reviewed R1's medication administration record. E1 reported R1 received assistance in the self-administration of Risperidone 1 mg, Trazadone 50 mg, and Oxcarbazepine 300 mg on November 30, 2025, at 7:00 PM, and Oxcarbazepine 300 mg on December 1, 2025, at 7:00 AM. The medication was not documented in R1's November MAR, and the December MAR has not been created. 6. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. This is a repeated violation from the complaint inspection conducted on July 31, 2025.

rule: R9-10-718.E.1. Medication Services E. When medication is stored at a behavioral health residential facility, an administrator shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

evidence: Based on observation and interview, the administrator failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for storage medication. The deficient practice posed a health and safety risk as medication stored by the facility was accessible to the residents.

findings: 1. The Compliance Officer observed a refrigerator in the facility’s unlocked garage. The Compliance Officer found a prescription bottle for R3, half full, for Fish Oil 1200 mg. 2. In an interview, E1 reported the door to the garage is normally locked, and residents do not have regular access to the garage. E1 reported R3 was a former resident of the facility. 3. In an exit interview, the findings were reviewed with E1, and no additional comments or statements were provided regarding the findings.

rule: R9-10-720.B.5. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 5. An evacuation drill for employees and residents on the premises is conducted at least once every six months on each shift;

evidence: Based on documentation review and interview, the administrator failed to ensure an evacuation drill for employees and residents on the premises was conducted at least once every six months on each shift. The deficient practice posed a safety risk if the employees were unable to implement the disaster plan.

findings: 1. In an interview, E1 reported the facility operates on two 12-hour shifts. 2. A review of facility documentation revealed documents titled "Evacuation Drill.” The forms were dated: September 6, 2025, at 4:20 pm; March 5, 2025, at 9:06 am; and September 6, 2024, at 10:20 am. The Compliance Officer observed no documentation of evacuation drills conducted at least once every six months on each shift was available for review. 3. In an interview, E1 reported E1 was unaware of the requirement to conduct evacuation drills at least once every six months on each shift. 4. In an exit interview, the findings were reviewed with E1, and no additional comments or statements were provided regarding the findings.