summary: Complaint - 8/28/2024

raw_content: An on-site investigation of complaint AZ00125162 was conducted on August 28, 2024 and the following deficiencies were cited :

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of residents.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "SECLUSION OR RESTRAINT" (dated in 2021). The policy stated "Our organization prides itself strongly in refraining from the use of physical interventions to manage behaviors. However, our staff is thoroughly trained to manage behaviors via verbal redirection, de-escalation, and therapeutic holds...Our staff is educated to recognize when residents become a danger to self or others, and intervene appropriately via verbal de-escalation techniques or coordination with crisis team/police. Therapeutic holds are only to be used where imminent danger is a factor and a resident has physically engaged himself or others in an attempt to cause bodily harm." 2. A review of facility documentation revealed an incident report dated in August 2024. The incident report stated "...[R1] run past staff into the office to attack the staff [E2]. [R1] threw a couple of punches from behind and staff [E2]grabbed [R1] to put [R1] in a hold. Staff [E2] did inaccurate and over excessive holding restraint..." However, E2 did not use verbal redirection, de-escalation, or a therapeutic hold. 3. A review of facility documentation revealed an incident report dated in August 2024). The incident report stated "After further investigation of incident...[R1] was in the backyard spraying a water hose...and then was told to stop by staff, [E2]...[R1] went to sit down on the backyard patio furniture and began using profanity directed towards [E2]. [E2] walked over to the bench/furniture and forced the bench back to where it began to tip at the edge of patio concrete...[E3] intervened to deescalate the situation...[R1] than stood up and began to start swinging on the staff, [E2]. A fight ensued to where [E2] used inappropriate hold technique on [R1]. Other staff, [E3] and [E4] had to separate the individuals. Everyone then came into the back into the home from outside. [E4] brought [E2] into the office to speak with [E2] about the interaction that happened in the backyard. During this time, [R1] was being monitored by staff, [E3] and was grabbing [R1's] shoes and attempting to AWOL. [E3] came into the office and advised that [R1] is attempting to AWOL...Then the 1st IR situation began..." However, E2 did not use verbal redirection, de-escalation, or a therapeutic hold. 4. A review of E2's (hired in August 2023) personnel record revealed E2 was hired as a behavioral health technician. The record revealed a document titled "Employee training checklist" with a line though "CPI." However, the record revealed a "Crisis Prevention and Intervention" training card issued in May 2024 by Sontarah Life Family Crisis Center (Sontarah). The record revealed E2's employment had been terminated. 5. The Compliance Officer observed the video footage which showed E2 had restrained R1. The video footage revealed R1 was on R1's back on the floor and E2 had E2's knee on R1's chest. Additionally, the video footage revealed E2 may have had one hand on R1's neck. 6. In an interview, E1 acknowledged E2 did not use techniques taught by Sontarah. El acknowledged sufficient personnel members were not present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of R1.

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration, for one of two residents sampled. The deficient practice posed a risk as R1 was subjected to a restraint.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "SECLUSION OR RESTRAINT" (dated in 2021). The policy stated "Our organization prides itself strongly in refraining from the use of physical interventions to manage behaviors. However, our staff is thoroughly trained to manage behaviors via verbal redirection, de-escalation, and therapeutic holds...Our staff is educated to recognize when residents become a danger to self or others, and intervene appropriately via verbal de-escalation techniques or coordination with crisis team/police. Therapeutic holds are only to be used where imminent danger is a factor and a resident has physically engaged himself or others in an attempt to cause bodily harm." 2. A review of facility documentation revealed an incident report (dated August 25, 2024). The incident report stated "...[R1] run past staff into the office to attack the staff. [R1] threw a couple of punches from behind and staff [E2] grabbed [R1] to put [R1] in a hold. Staff [E2] did inaccurate and over excessive holding restraint..." 3. A review of facility documentation revealed an incident report (dated August 26, 2024). The incident report stated "After further investigation of incident...[R1] was in the backyard spraying a water hose...and then was told to stop by staff, [E2]...[R1] went to sit down on the backyard patio furniture and began using profanity directed towards [E2]. [E2] walked over to the bench/furniture and forced the bench back to where it began to tip at the edge of patio concrete...[E3] intervened to deescalate the situation...[R1] than stood up and began to start swinging on the staff, [E2]. A fight ensued to where [E2] used inappropriate hold technique on [R1]. Other staff, [E3] and [E4] had to separate the individuals. Everyone then came into the back into the home from outside. [E4] brought [E2] into the office to speak with [E2] about the interaction that happened in the backyard. During this time, [R1] was being monitored by staff, [E3] and was grabbing [R1's] shoes and attempting to AWOL. [E3] came into the office and advised that [R1] is attempting to AWOL...Then the 1st IR situation began..." 4. A review of E2's (hired in August 2023) personnel record revealed E2 was hired as a behavioral health technician. The record revealed a document titled "Employee training checklist" with a line though "CPI." However, the record revealed a "Crisis Prevention and Intervention" training card issued in May 2024 by Sontarah Life Family Crisis Center (Sontarah). The record revealed E2's employment had been terminated. 5. The Compliance Officer observed the video footage which showed E2 had restrained R1. The video footage revealed R1 was on R1's back on the floor and E2 had E2's knee on R1's chest. Additionally, the video footage revealed E2 may have had one hand on R1's neck. 6. In an interview, E1 acknowledged the administrator failed to ensure a resident was treated with dignity, respect, and consideration. E1 reported the incident was reported to the department of child safety.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident was not subjected to a restraint, for one of two residents sampled. The deficient practice posed a potential for psychological distress and physical injury.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "SECLUSION OR RESTRAINT" (dated in 2021). The policy stated "Our organization prides itself strongly in refraining from the use of physical interventions to manage behaviors. However, our staff is thoroughly trained to manage behaviors via verbal redirection, de-escalation, and therapeutic holds...Our staff is educated to recognize when residents become a danger to self or others, and intervene appropriately via verbal de-escalation techniques or coordination with crisis team/police. Therapeutic holds are only to be used where imminent danger is a factor and a resident has physically engaged himself or others in an attempt to cause bodily harm." 2. A review of facility documentation revealed an incident report dated in August 2024). The incident report stated "...[R1] run past staff into the office to attack the staff. [R1] threw a couple of punches from behind and staff [E2] grabbed [R1] to put [R1] in a hold. Staff [E2] did inaccurate and over excessive holding restraint..." 3. A review of facility documentation revealed an incident report dated in August 2024. The incident report stated "After further investigation of incident...[R1] was in the backyard spraying a water hose...and then was told to stop by staff, [E2]...[R1] went to sit down on the backyard patio furniture and began using profanity directed towards [E2]. [E2] walked over to the bench/furniture and forced the bench back to where it began to tip at the edge of patio concrete...[E3] intervened to deescalate the situation...[R1] than stood up and began to start swinging on the staff, [E2]. A fight ensued to where [E2] used inappropriate hold technique on [R1]. Other staff, [E3] and [E4] had to separate the individuals. Everyone then came into the back into the home from outside. [E4] brought [E2] into the office to speak with [E2] about the interaction that happened in the backyard. During this time, [R1] was being monitored by staff, [E3] and was grabbing [R1's] shoes and attempting to AWOL. [E3] came into the office and advised that [R1] is attempting to AWOL...Then the 1st IR situation began..." 4. A review of E2's (hired in August 2023) personnel record revealed E2 was hired as a behavioral health technician. The record revealed a document titled "Employee training checklist" with a line though "CPI." However, the record revealed a "Crisis Prevention and Intervention" training card issued in May 2024 by Sontarah Life Family Crisis Center (Sontarah). The record revealed E2's employment had been terminated. 5. The Compliance Officer observed the video footage which showed E2 had restrained R1. The video footage revealed R1 was on R1's back on the floor and E2 had E2's knee on R1's chest. Additionally, the video footage revealed E2 may have had one hand on R1's neck. 6. In an interview, E1 acknowledged the administrator failed to ensure R1 was not subjected to a restraint. E1 reported the incident was reported to the department of child safety.


state: AZ

facility_name: A CARING COMMUNITY LLC

summary: Compliance (Annual) - 5/20/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on May 20, 2024:

inspection_type: Compliance (Annual)

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 observation, record review, documentation review, and interview, 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\'a7 36-425.03(A), for one of seven personnel records sampled. The deficient practice posed a risk if E5 was a danger to a vulnerable population.

findings: A.R.S. \'a7 36-425.03(A) states "Except as provided in subsections B, C and D of this section, children's behavioral health program personnel, including volunteers, shall submit the form prescribed in subsection E of this section to the employer and shall have a valid fingerprint clearance card issued pursuant to title 41, chapter 12, article 3.1 or, within seven working days after employment or beginning volunteer work, shall apply for a fingerprint clearance card." 1. The Compliance Officer observed E5 on the premises and working alone when the Compliance Officer arrived at 8:45AM. 2. A review of E5's (hired in 2021) personnel record revealed E5 was hired as a behavioral health technician. E5's personnel record revealed a fingerprint clearance card (issued February 22, 2018, expired February 22, 2024). However, documentation of a valid fingerprint clearance card was not available for review. 3. A review of the Arizona Department of Public Safety (AZDPS) Fingerprint Clearance Status website revealed E5's fingerprint clearance card application was received by AZDPS on February 13, 2024 and the status was "Waiting on Applicant Fingerprints." 4. In an interview, E1 acknowledged E5's personnel record was not maintained to include documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(A).

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;

evidence: Based on documentation review and interview, the administrator failed to ensure there was a daily staffing schedule to indicate the scheduled work hours, and name of each employee assigned to work, including on-call personnel members. The deficient practice posed a risk if there was no record to ensure shifts and tasks were covered.

findings: 1. A review of facility documentation revealed a daily staffing schedule for April 28, 2024-May 26, 2024. However, the daily staffing schedule did not include the behavioral health professional and registered nurse as on-call personnel members. 2. In an interview, E1 acknowledged the daily staffing schedules indicating the date, scheduled work hours, and name of each employee assigned to work, did not include the behavioral health professional and registered nurse as on-call personnel members.

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 and documented the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission, for one of two 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 R2's (admitted in 2024) medical record revealed a medical history and physical examination performed by a medical practitioner or a nursing assessment performed by a registered nurse was not available for review. 2. In an interview, E1 reported a medical history and physical examination performed by a medical practitioner or a nursing assessment performed by a registered nurse had not been performed. 3. In an interview, E1 acknowledged a medical history and physical examination performed by a medical practitioner or a nursing assessment performed by a registered nurse was not available for review.

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, and as specified in R9-10-113, for one of two residents sampled.

findings: 1. A review of R1's (admitted in 2023) medical record revealed evidence of freedom from infectious TB, before or within seven calendar days after R1's admission, and as specified in R9-10-113, was not available for review. 2. In an interview, E1 reported R1 did not have documentation of evidence of freedom from infectious TB and acknowledged R1's evidence of freedom from infectious TB was not available for review.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: b. The physical health services or behavioral health services to be provided to the resident;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a treatment plan included the behavioral health services to be provided to the resident, for two of two residents sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements of services to be provided.

findings: R9-10-101.24. "Assistance in the self-administration of medication" means restricting a patient's access to the patient's medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. R9-10-101.135. "Medication administration" means restricting a patient's access to the patient's medication and providing the medication to the patient or applying the medication to the patient's body, as ordered by a medical practitioner. 1. A review of facility documentation revealed a scope of services (date unavailable). The scope of services stated "... SERVICES Provided daily: Assistance in the self-administration of medication." 2. A review of R1's (admitted in 2023) medical record revealed a treatment plan (dated in 2023). However, R1's treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R1 . 3. A review of R2's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). However, R2's treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R2 . 4. In an interview, E1 reported medication administration was provided to R1, R2, and all residents by prepping the medications and placing the medications in a cup, and handing the cup to the residents. 5. In an interview, E1 acknowledged R1's and R2's treatment plans did not include the behavioral health services to be provided to the residents. Technical assistance was provided on this Rule during the during the on-site compliance inspection conducted on February 24, 2023.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: d. The date when the resident's treatment plan will be reviewed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan for each resident included the date the treatment plan was to be reviewed, for two of two residents sampled. The deficient practice posed a risk as treatment plans reinforce and clarify services to be provided to a resident.

findings: 1. A review of R1's (admitted in 2023) medical record revealed a treatment plan (dated in 2023). However, the treatment plan did not include the date the treatment plan was to be reviewed. 2. A review of R2's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). However, the treatment plan did not include the date the treatment plan was to be reviewed. 3. In an interview, E1 acknowledged R1's and R2's treatment plans did not include the date the treatment plans were to be reviewed.

rule: A. An administrator shall ensure that: 4. Behavioral health services are provided to meet the needs of a resident and are consistent with a behavioral health residential facility's scope of services;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure behavioral health services were consistent with a behavioral health residential facility's scope of services. The deficient practice posed a risk as the resident was expected to receive medication administration and the facility's scope of services did not include medication administration.

findings: R9-10-101.24. "Assistance in the self-administration of medication" means restricting a patient's access to the patient's medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. R9-10-101.135. "Medication administration" means restricting a patient's access to the patient's medication and providing the medication to the patient or applying the medication to the patient's body, as ordered by a medical practitioner. 1. A review of facility documentation revealed a scope of services (date unavailable). The scope of services stated "... SERVICES Provided daily: Assistance in the self-administration of medication." 2. A review of facility documentation revealed a policy and procedure titled "Section 16: Medication Services" (date unavailable). The policy and procedure stated " ... Although only residents may touch the medications, all staff must was their hands ... Staff members should sit at a table with the resident's medication container/bottle/package on table. ... Staff members checks the resident's medi-set or printed bottle for resident's name, mg, and number of tabs, to be observed at that time. Staff members asks the resident hot many tabs he/she is to take. ... Resident then puts the correct number of tabs into his/her hand or cup and shows staff. ... Resident should administer the medication while staff member observes. Resident closes the prescription bottle or medi-set and hands it back to the staff member." However, policies and procedures to cover administering medication was not available for review. 3. A review of R1's (admitted in 2023) medical record revealed a treatment plan (dated in 2023). However, R1's treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R1 . 4. A review of R2's (admitted in 2024) medical record revealed a treatment plan (dated in 2024). However, R2's treatment plan did not include whether medication administration or assistance in the self-administration of medication was to be provided to R2 . 5. In an interview, E1 reported medication administration was provided to R1, R2, and all residents by prepping the medications and placing the medications in a cup, and handing the cup to the residents. 6. In an interview, E1 acknowledged services provided were not consistent with a behavioral health residential facility's scope of services.


summary: Complaint - 6/15/2023 - 6/22/2023

raw_content: This new Statement of Deficiencies supercedes the Statement of Deficiencies sent to the licensee on June 28, 2023. An on-site investigation of complaints AZ00196572 and AL00196620 was conducted on June 15, 2023, an off-site documentation review was completed on June 22, 2023, and the following deficiency was cited :

inspection_type: Complaint

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 compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(E), for one of nine personnel records sampled. The deficient practice posed a risk if E6 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. A review of E6's (hired in 2023) personnel record revealed E6 was hired as a behavioral health technician (BHT). E6's personnel record revealed a valid fingerprint clearance card and a form (dated January 16, 2023) indicating E6 was 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. However, the form was not notarized. 2. In an interview, E2 reported E2 believed E6 had a notarized form indicating E6 was 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 3. In an interview, E2 acknowledged E6's personnel record was not maintained to include documentation of compliance with the requirements in A.R.S. \'a7\'a7 36-425.03(E). This is a repeat deficiency from the compliance inspection conducted on February 24, 2023.

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 participate in any activity to 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. The deficient practice posed a risk as residents participated in an activity where a registered sex offender was present.

findings: 1. A review of Department documentation revealed BH6807 was licensed as a children's behavioral health residential facility with a capacity of five beds. 2. A review of medical records revealed AL6809 had five residents. 3. A review of the Arizona E-Licensing database for Arizona Professional Licensure (https://elicense.az.gov/ARDC_HomePage) revealed O1 was licensed as a student barber with the Arizona State Board of Barbers. The database revealed an address to correlate with cross streets provided by E2 for O1's place of business. 4. In an interview, R1 reported R1 received haircut services from O1. 5. In an interview, E1 reported the residents received haircut services from O1. E1 reported the residents and O1 were always supervised. 6. In an interview, E2 reported the residents received haircut services from O1. E2 reported E2 did not know the name of the barbershop but provided the Compliance Officers with the cross streets. 7. A review of facility documentation revealed a receipt for haircut services (dated June 7, 2023). The receipt stated "Hey [E1], Thanks for booking with [O1] using theCut! APPOINTMENT Hair Cuts For Kids Under 18." 8. In an interview, R1 reported R1 observed O1 on the premises to fix a broken toilet. 9. In an interview, E2 stated the toilet O1 fixed the toilet "this week" and the toilet "flooded on Tuesday." 10. In an interview, E1 reported O1 only does minor work at the facility. E1 reported O1 was at the facility to fix the toilet and to install outdoor screens on the windows. E1 reported the residents and O1 were always supervised. 11. In an interview, E1 reported E1 was aware of O1's background. E1 reported E1 takes O1's background seriously and O1 was not involved in the behavioral health residential facility. 12. In an interview, E2 reported E2 was aware O1 does minor work at the facility. E2 reported E2 has never personally seen O1 on the premises. E2 reported E2 believed the residents and O1 were always supervised. 13. In an interview, E2 acknowledged E1 failed to ensure a resident did not participate in any activity to present a threat to the resident's health or safety. 14. A review of the State of Idaho court cases website (https://mycourts.idaho.gov/) revealed a Criminal Court Case Information Case History for O1. The website stated "Rape-Female Under the age of 18 (Statutory Rape)" in 2001; "PROBATION VIOLATION" in 2006; "Probation Violation" in 2008; and "Sex Offender-Give False Information in Registration ... Sex Offender-Fail to Register or Give False Information" in 2009. 15. In an email, received by the Department on June 22, 2023, a representative from the Arizona Department of Public Safety (AZDPS), O2, reported O1 was currently registered as a sex offender in Arizona.


facility_name: Arizona Community Protection And Treatment Center

summary: Complaint - 2/11/2026 - 2/13/2026

raw_content:
The following deficiency was cited at the time of the unannounced, on-site State Complaint Investigation survey conducted on February 11, 2026, through February 13, 2026, pursuant to the rules found in Arizona Administrative Code (A.C.C.) Title 9, Article 13: Behavioral Health Specialized Transitional Facility, for the following intakes:

00155558
00150035

Healthcare Compliance Officers
February 13, 2026

rule: R9-10-1302.C.1.t. Administration C. An administrator shall: 1. Ensure that policies and procedures are established, documented, and implemented that: t. Cover quality management, including incident reports and supporting documentation;

evidence: Based on a facility policy and procedure review, facility documentation review, patient medical record review and request, and employee interview, the Department determined that the administrator failed to ensure that documentation of nursing assessments offered to patients involved in patient-to-patient physical assault incidents. This deficient practice poses a risk that patient-to-patient physical assault incidents are not assessed and subsequently treated for any potential and/or actual injuries incurred from a physical assault incident, which can pose a threat to the health and safety of patients.

findings: A review of facility policy titled “Incident Reporting,” effective November 25, 2024, revealed: “…If a resident is the victim of an assault, the charge nurse will offer to assess the resident and document the findings as soon as possible….” A review of facility documentation, dated 5/15/2025, revealed that on 05/15/2025, patient #6 was witnessed by staff to be pushed by another patient. A review of patient #6’s “Progress Notes,” dated 05/15/25, revealed: “…Staff was standing next to doorway…when a resident came up from behind and pushed resident…staff redirected both residents…Staff updated the day shift staff….” A request was made for documentation regarding the offer for a nurse to assess patient #6 after the incident on 05/25/2025. None was provided at the time of survey. A request was made for patient #6’s nursing assessment after the incident on 05/15/2025. None was provided at the time of survey. An interview with employee #1, and #4, completed on February 11, 2026, confirmed that documentation regarding an offer for a nurse to assess patient #6, or patient #6’s nursing assessment after the incident on 05/15/2025, could not be provided.


summary: Compliance (Annual) - 2/11/2026 - 2/13/2026

raw_content:
The following deficiencies were cited at the time of the unannounced, on-site State Compliance survey conducted on February 11, 2026, through February 13, 2026, pursuant to the rules found in Arizona Administrative Code (A.C.C.) Title 9, Article 13: Behavioral Health Specialized Transitional Facility.

Healthcare Compliance Officers
February 13, 2026

rule: R9-10-1308.1.b. Transport An administrator shall ensure that: 1. A vehicle used to provide transportation a patient: b. Contains a locked first aid kit that holds first aid supplies in a quantity sufficient to meet the needs of the transported patients,

evidence: Based on observation during on-site tour and employee interview, the Department determined the Administrator failed to ensure first aid kits in facility vehicles are locked. This deficient practice poses the risk of unauthorized access to the kits, potentially enabling harm to patients or others.

findings: Observation during on-site tour, conducted on February 12, 2026, revealed the following: Facility vehicle 10D074 – First Aid kit observed unlocked, stowed in the rear compartment area of the vehicle. Facility vehicle 10B654 – First Aid kit observed unlocked, stowed in the rear compartment area of the vehicle. Facility vehicle 10B134 – First Aid kit observed unlocked, stowed in the rear compartment area of the vehicle. Employees #1 and #4 confirmed, during interviews conducted on February 12, 2026, that facility vehicles #10D074, #10B654, and #10B134, contained First Aid kits that were not locked.

rule: R9-10-1312.A.3.b. Patient Records A. An administrator shall ensure that: 3. An order is: b. Authenticated by a medical practitioner or behavioral health professional according to facility policies and procedures; and

evidence: Based on facility policy and procedure request, facility documents, medical records, medical record request, and employee interviews, the Department determined the Administrator failed to ensure the facility had policies and procedures for orders and verbal orders so that providers understood the requirements on authenticating orders and nurses taking verbal orders knew the process. This deficient practice poses the potential risk that patient treatments ordered by a medical practitioner are not implemented, or not implemented as directed.

findings: Request was made for facility policy and procedure addressing medical practitioner orders, including verbal orders. None was provided. Facility documents revealed the following: Document dated 2/5/2026, referencing Patient #8, stated “…Resident was complaining of having trouble breathing, the chills and a feeling of discomfort…The on-call physician was notified at approximately 0015 and stated that (he/she) was initially going to send the patient to the ER, but stated that (he/she) wanted medical staff to keep an eye on the resident, put (him/her) on sick call and check (his/her) vital signs during the rest of the shift….” Medical record for Patient #8 revealed the following: Document titled “Progress Notes,” dated 02/05/26 and documented by Employee #17, stated “…The on-call physician was notified at approximately 0015 and stated that (he/she) was initially going to send the patient to the ER, but stated that (he/she) wanted medical staff to keep an eye on the patient, put (him/her) on the sick call list and to check (his/her) vital signs during the rest of the shift….” Request was made for authenticated medical practitioner orders documenting the direction, from the Progress Note documented by Employee #17 on 02/05/26, “…to keep an eye on the patient, put (him/her) on the sick call list and to check (his/her) vital signs during the rest of the shift….” None was provided. Employees #1, #2, and #4 confirmed, during interviews conducted on February 12, 2026 and February 13, 2026, that no facility policy and procedure addressing medical practitioner orders, including verbal orders, or documented and authenticated medical practitioner orders, as noted above, were available for review at the time of the survey.

rule: R9-10-1312.A.3.c. Patient Records A. An administrator shall ensure that: 3. An order is: c. If the order is a verbal order, authenticated by the medical practitioner or behavioral health professional issuing the order;

evidence: Based on facility policy and procedure, policy and procedure request, facility document, medical records, medical record request, and employee interviews, the Department determined the Administrator failed to ensure medical practitioner verbal orders were documented, authenticated and implemented. This deficient practice poses the potential risk that patient treatments ordered by a medical practitioner are not implemented, or not implemented as directed, adversely impacting patient care.

findings: Facility policy titled “Emergency Codes,” Effective Date 5/1/2023, revealed “…B. Medical Alert and Code Blue (Medical Emergency):…1. A Medical Alert is called when medical attention is needed emergently. A Code Blue is initiated in response to a suspected or eminent cardiopulmonary arrest or a medical emergency requiring the immediate attention of a physician/medical provider….” Facility policy titled “Transporting and Escorting Residents,” Effective Date June 24, 2024, revealed “…GENERAL GUIDELINES…4. All applicable clinical disciplines are to complete documentation according to the established Policy and Procedure for the following circumstances:…b. Resident transfers to emergency services/medical facility….” Request was made for facility policy and procedure addressing medical practitioner orders, including verbal orders. None was provided. Facility documents revealed the following: Document dated 2/5/2026, referencing Patient #8, stated “…Around 2330 (Employee #11) was going to medical to get a resident packet for the morning and noticed (Employee #17) going to Mesquite to check on resident (Patient #8)…(Employee #11) went with (Employee #17) and we approached Resident…and (he/she) was complaining of shaking and complaining that he was very cold…When asked how long this was happening (Patient #8) said around 8PM (2000)…(Employee #17) decided to check on him at medical so we escorted the resident by wheelchair to medical…(Employee #17) check (his/her) vitals and later on called the PNC and later on the doctor…First the doctor wanted (him/her) to go to (other facility) so a medical code was called… Few minutes later security and Acacia 1 staff arrived and while (Employee #11) set up staff to take Resident (Patient #8) to (other facility)…hospital and have security get us a wheelchair van (Employee #11) was informed by PNC and RN that the doctor cancelled the order….” Medical record for Patient #8 revealed the following: Document titled “Progress Notes,” dated and timed 02/05/26 12:25 AM, and documented by Employee #18, stated “…N:…Pt, who has hx of COPD, reported difficulty breathing at 8 PM, and currently (his/her) pulse ox at 88% and pulse ranging from 144-150…I/R:…Transfer to ER for hypoxemia (pulse of dropped to 88%)…Additional Note Written By: (Employee #18) On: 02/05/26 At: 12:31 AM…Appended Note…Addendum…When unit nurse administered albuterol inhaler at about 0025, (his/her) pulse ox increased to 91%...Will discontinue the plan to send pt to ER….” Document titled “Order Detail Report” stated “…Order Description: albuterol (Ventolin HFA) 90 mcg/actuation suspension INHALATION…Order Status: Active…Start Date/Time: 11/20/2025 12:24 PM…Stop Date/Time: 11/20/2026 12:23 PM…Frequency: Q4HPRN—Q4HPRN One Time Every 4 Hours PRN…Reason Text: shortness of breath or wheezing….” Document titled “Progress Notes,” dated 02/05/26 and documented by Employee #17, stated “…The patient was complaining of having trouble breathing, the chills and a feeling of discomfort…The on-call physician was notified at approximately 0015 and stated that (he/she) was initially going to send the patient to the emergency department, but stated that (he/she) wanted medical staff to keep an eye on the patient, put (him/her) on the sick call list and to check (his/her) vital signs during the rest of the shift…The patient vital signs were at approximately 23:35 T-101.5 BP-158/81 HR-149 O2-96 and RR-18…At approximately 23:30 the patient’s vital signs were T-100 HR-147 BP-135/82 O2 94 and RR-16…At approximately 00:15 the patient vital signs were T-99.1 BP-121/70 HR-144 RR-18 and O2-94…At approximately 02:30 AM the patient’s vital signs were T-98.2 BP-116/70 P-119 O2-96 and RR-18….” Request was made for provider orders pertaining to this incident. None were provided. Request was made for clarification on how often the provider order was for "check (his/her) vital signs during the rest of the shift." None was provided. Orders for the verbal order to send to the emergency room and the discontinuation of that order were requested. None were provided. Employees #1, #2, and #4 confirmed, during interviews conducted on February 12, 2026 and February 13, 2026, that no provider orders for this incident were available for review at the time of the survey.

rule: R9-10-1314.B.1.c. Food Services B. A registered dietitian or director of food services shall ensure that: 1. A food menu: c. Is conspicuously posted at least one day before the first meal on the food menu will be served,

evidence: Based on facility policy and procedure review and request, facility premises tour observations, and employee interview, the Department determined that the administrator failed to ensure that current menus are conspicuously posted. This deficient practice poses a risk of patients experiencing anxiety, patient food refusal, patient malnutrition, and a loss of patient autonomy, which can pose a threat of harm to the health and safety of patients.

findings: A request was made specifically for facility policy and procedure related to patient menu posting requirements. None was provided during the time of survey. A facility premises tour, completed on February 11, 2026, revealed the following observations: Acacia 1 Unit: Hallway: Menu posting was dated 9/2025. Acacia 2 Unit: Hallway: Menu posting was dated 9/2025. An interview with employee #1, and #4, completed on February 11, 2026, confirmed that menu postings in both the acacia 1 unit, and acacia 2 unit hallways were dated 9/2025.

rule: R9-10-1315.A.2. Emergency and Safety Standards A. A medical director shall ensure that policies and procedures for providing medical emergency treatment to a patient are established, documented, and implemented and include: 2. A system to ensure all medications, supplies, and equipment are available, have not been tampered with, and, if applicable, have not expired;

evidence: Based on facility policy and procedure review, facility premises tour observations, and employee interview, the Department determined that the administrator failed to ensure that available medical supplies are not expired. This deficient practice poses potential risks of staff using ineffective medical supplies to provide treatment to patients, which can pose risks to the health and safety of patients.

findings: A review of facility policy titled “Emergency Operations Plan FY 2026 Edition,” revised 6/30/2025, revealed: "... Supplies, with expiration dates, are kept current through monitoring by the Medical Services Department...Medical Supplies...." A facility premises tour, completed on February 11, 2026, revealed the following observations: Acacia 2 Nursing Unit: Emergency Cart revealed: “…HEARTSTART…SMART PADS II…⌛2025-09-10….” Vehicle #10B654: First aid kit revealed: “…First Aid/Burn Cream…EXP 01/2025….” First aid kit revealed: “…EYEWASH…EXP JULY 2025….” Employee #1, and #4 confirmed in an interview, completed on February 11, 2026, that medical supplies identified in the acacia 2 nursing unit, and vehicle #10B654, were beyond the expiration date.


summary: Complaint - 10/28/2025 - 11/6/2025

raw_content:
The following deficiencies were cited at the time of the unannounced, on-site State Complaint Investigation Survey conducted from October 28, 2025 to November 6, 2025, pursuant to the rules found in Arizona Administrative Code (A.A.C.) Title 9, Chapter 10, Article 13- Behavioral Health Specialized Transitional Facility, for the following case numbers:

00092959
00092966
00122448
00124518
00124540
00128765
00129046
00130986
00140950
00146349
00147983
00148582
00148964

Healthcare Compliance Officers
November 6, 2025

rule: R9-10-1302.H.1-4. Administration H. A clinical director: 1. Is responsible for the behavioral health services provided to patients; 2. Shall ensure that policies and procedures are established, documented, and implemented to protect the health and safety of a patient that cover: a. Assessing the competency and proficiency of a behavioral health personnel member for each type of service the personnel member provides and each type of patient to which the personnel member is assigned; b. Providing: i. Supervision to behavioral health paraprofessionals, according to R9-10-115(2); and ii. Clinical oversight to behavioral health technicians, according to R9-10-115(3); c. The qualifications for personnel members who provide clinical oversight; d. The process for patient assessments, including the identification of and criteria for the on-going monitoring of a patient’s behavioral health issues; e. The process for developing and implementing a patient’s treatment plan; f. The frequency of and process for reviewing and modifying a patient’s treatment plan, based on the ongoing monitoring of the patient’s response to treatment; and g. The process for determining whether a patient is eligible for discharge or conditional release to a less restrictive alternative; 3. Shall ensure that patient services are provided by personnel that are competent and proficient in providing the services; and 4. Shall ensure that clinical oversight of personnel members is provided according to the policies and procedures.

evidence: R9-10-1302. Administration H. A clinical director: 3. Shall ensure that patient services are provided by personnel that are competent and proficient in providing the services; and Based on hospital policy and procedure review, hospital video monitoring footage review, hospital documentation review, personnel file review, employee hospital video monitoring footage review, and employee interview, the Department determined that the administrator failed to ensure that staff engaging in supportive patient lifts/transfers are competent and proficient in providing the transfers. This deficient practice poses significant risks for patient fall, musculoskeletal, and/or skin injuries; pain/discomfort; and/or clinical deterioration for patients, which could contribute to patient morbidity and/or mortality.

findings: A review of hospital policy titled “Staff Orientation and Training,” effective August 26, 2024, revealed: “…supervisors are responsible for ensuring that their staff is adequately trained to perform their assigned duties and responsibilities in a competent manner….” A review of hospital policy titled “Residential Program Specialist 2,” revealed: “…Job Summary…assists infirm residents in walking/transferring…lift and reposition residents as needed….” A review of hospital video monitoring footage titled “Indigo Lobby CAM IA.05,” dated 10/26/2025, from 7:43:38 PM to 8:18:46 PM, revealed at 7:45:15 PM, and at 8:01:50 PM, employee #6, and #13 attempted to engage in supportive patient lifts/transfers with patient #12. Employee #6, and #13 were at each side of patient #12, attempting to lift up patient #12 from a wheelchair under his/her arms. A review of hospital documentation titled “Education Days 2025 – Passport,” revealed: “…Booth 16 – Falls/Transfers…” training, which included competency training checklists for independent patient transfer and single person transfer. A review of employee #6’s personnel file documentation titled “Education Days 2025 – Passport,” revealed: “…Booth 16 – Falls/Transfers…” training, which included competency training checklists for independent patient transfer and single person transfer, was completed by employee #6 on 10/6/2025. A review of employee #13’s personnel file documentation titled “Education Days 2025 – Passport,” revealed: “…Booth 16 – Falls/Transfers…” training, which included competency training checklists for independent patient transfer and single person transfer, was completed by employee #13 on 10/7/2025. An employee review of patient #12’s hospital video monitoring footage titled “Indigo Lobby CAM IA.05,” dated 10/26/2025, at 7:45:15 PM, and at 8:01:50 PM, was completed with employee #10 on 11/06/2025. Employee #10 confirmed that on 10/26/2025, at 7:45:15 PM, and at 8:01:50 PM, employee #6, and #13 attempted to engage in supportive patient lifts/transfers with patient #12. An interview with employee #10, completed on 11/06/2025, confirmed upon review of hospital video monitoring, dated 10/26/2025, at 7:45:15 PM, and at 8:01:50 PM, that employee #6, and #13 engaged in inappropriate lifts/transfers with patient #12, stating “…(patient #12’s) definitely slouching…they need to reposition (patient #12)…they’re already not in a good position…they’re supposed to be in front of (patient #12) instead of (patient #12’s) sides…they’re lifting by (patient #12’s) underarms…it’s not what we teach them to do…it could dislocate (patient #12’s) shoulder joint, or pull something out of socket ....”

rule: R9-10-1302.G.1-2 . Administration G. A medical director: 1. Is responsible for the medical services, nursing services, and physical health-related services provided to patients consistent with the patients behavioral treatment plan; and 2. Shall ensure that policies and procedures are established, documented, and implemented to protect the health and safety of a patient that cover: a. Restraint and seclusion, according to R9-10-225; b. The process for patient assessments, including the identification of and criteria for the on-going monitoring of a patient’s physical health conditions;

evidence: R9-10-1302.G.2.b. Based on facility policy and procedure, primary professional source review, hospital documentation review, medical record review, and employee interview, the Department determined the Medical Director failed to ensure a process for patient assessments was implemented. This deficient practice resulted in inadequate or absent patient assessments, which may have contributed to a patient death.

findings: Facility policy titled “ASSESSMENT OF THE RESIDENT,” Effective Date November 1, 2025, revealed “…B. HISTORY AND PHYSICAL EXAMINATION… 5. Reexamination of the resident’s physical status will be performed as follows:…a. When resident exhibits signs of illness;… d. The Officer of the Day/ On Call Medical Practitioner will assume the responsibility for the re-examination of the resident’s physical status and required documentation of said reexamination between the hours of 1700 and 0800, Monday through Friday, and on weekends and holidays. Within 72 hours the attending medical practitioner will then reexamine the resident’s physical status and place appropriate documentation in the resident’s medical record… C. NURSING SERVICES ASSESSMENT… 3. An RN will perform a complete Nursing Assessment annually within the anniversary month of the resident’s admission. An RN’s assessment of the resident’s medical condition is completed in response to resident complaints, including pain, or other physical needs or observations that are reported or detected or any time there is a change in the resident’s condition….” A review of the National Institutes of Health (NIH) website (2011) and Nursing Fundamentals [Internet]. 2nd Edition. Open Resources for Nursing (Open RN); Ernstmeyer K., Christman E., editors. Eau Claire (WI): Chippewa Valley Technical College: 2024., revealed “…4.3. Assessment… Assessment is the first step of the nursing process (and the first Standard of Practice by the American Nurses Association). This standard is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation…Sources of Assessment Data…There are three sources of assessment data: interview, physical examination, and review of laboratory or diagnostic test results…A physical examination is a systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. Inspection is the observation of a client’s anatomical structures. Auscultation is listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope. Palpation is the use of touch to evaluate organs for size, location, or tenderness. Percussion is an advanced physical examination technique typically performed by providers where body parts are tapped with fingers to determine their size and if fluid or air are present. Detailed physical examination procedures of various body systems can be found in the Open RN Nursing Skills, 2e textbook with a head-to-toe checklist in Appendix C. Physical examination also includes the collection and analysis of vital signs…A physical examination can be performed as a comprehensive head-to-toe assessment or as a focused assessment related to a particular condition or problem. Assessment data is documented in the client’s medical record, either in their electronic medical record (EMR) or their paper chart, depending upon agency policies and procedures….” Facility email documentation titled “Gmail…Fwd: Residents (Patient #15) & (Patient #12), dated 10/26/2025 and sent by Employee #16, revealed: “…(Patient #12) has been having NVD (Nausea, Vomiting, Diarrhea) the last few days. I believe (Patient #12) is coming out of it but this morning (Patient #12) came for meds (missed the previous 2 morning meds) and (Patient #12) was quite dramatic about (Patient #12’s) feelings of distress…(Patient #12) said (Patient #12) wanted to be sent to the ED and I told (Patient #12) no, not necessary…(Patient #15) reported that (Patient #15) cannot stop urinating and…has never urinated this much in (Patient #15’s) life. It’s keeping (Patient #15) up most of the last two nights….” Medical record review revealed the following: Patient #12 Document titled “Progress Notes,” authored by Employee #16, dated and timed at 10/26/25 09:45 AM, revealed “…During the NOC shift at approximately 0245, while (Employee #16) was doing rounds…(Patient #12) requested to see nursing. Nursing observed (Patient #12) laying in bed with a garbage can in the bed with (Patient #12) as well as a 'go-back' meal from lunch and one from dinner. (Patient #12) informed nursing that (Patient #12) just threw up. (Patient #12) appeared to have an exaggerated look of despair and distress. (Patient #12) has had gastrointestinal symptoms the last 48-72 hours, with diarrhea and (Patient #12) is now reporting nausea and vomiting. Staff has not been witness to any episodes of vomiting. Nursing saw the meals on the bed and inquired as to why (Patient #12) has them in…bed when (Patient #12) just reported vomiting. (Patient #12) did not give nursing or RPS staff an answer. (Patient #12) had a banana with one meal and an apple sauce with another which nursing told (Patient #12) and staff that (Patient #12) should keep and remove the rest of the food. (Patient #12) informed nursing that…nausea was subsiding and…didn't have diarrhea anymore but…did feel "really bloated" and gassy. Nursing pulled Mylanta for (Patient #12) which took [sic] and left (Patient #12) to get more sleep….” Document titled “Progress Notes,” authored by Employee #16, dated and timed at 10/26/25 09:48 AM, revealed “…(Patient #12) came to medical for AM med pass today at approximately 0730. Since (Patient #12) has had gastrointestinal symptoms the last 48 hours, (Patient #12) has not come for morning meds…(Patient #12) arrived today via w/c with another resident pushing (Patient #12) and taking care of all of (Patient #12’s) needs (i.e. getting…cups of water, tissues etc.)…Nursing provided (Patient #12) morning medications, which included PRN pain medications as well as scheduled pain medications. After (Patient #12) took…medications (Patient #12) lingered at the med window so nursing inquired to (Patient #12’s) needs. (Patient #12) stated "I want to know what you are going to do with me"? Unknown what (Patient #12) was referring to, nursing asked (Patient #12) to clarify, which (Patient #12) stated "I've been sick, what are you going to do"…Nursing asked (Patient #12), "what would you like nursing to do for you?" (Patient #12) wanted to go to the hospital. Nursing explained that a stomach bug is not usually something that requires a visit to the ED and educated (Patient #12) that (Patient #12’s) body is trying to remove what should not be in there and usually a stomach bug lasts around 72 hours which (Patient #12) is close to. Nursing further reminded (Patient #12) that (Patient #12) told (Employee #16) during the NOC shift encounter that (Patient #12) had not had another episode of vomiting and that (Patient #12’s) diarrhea had gotten better. Nursing informed (Patient #12) that the medical provider will assess (Patient #12) tomorrow morning (Monday) and determine if (Patient #12) needs to be sent out for an ER visit. After morning meds finished, while (Employee #16) was cleaning up, an…RPS staff member came into the building to inform nursing that (Patient #12) was being assisted with (Patient #12’s) shower and that (Patient #12) reporting [sic] intense pain in various parts of (Patient #12’s) body…told the RPS that (Patient #12) thinks (Patient #12) has to go to the hospital. Nursing explained to the RPS that (Patient #12) just took multiple pain medications less than 45 minutes prior and that (Patient #12) was just wanting to go to the hospital for…gastrointestinal symptoms at that time as well. Asked the RPS staff member to contact medical that we should wait and see how (Patient #12) is after the pain meds kick in and…morning shower/hygiene is done and to contact medical if symptoms appear to be worse or (Patient #12’s) situation changes in anyway….” Request was made for the documentation of the RN’s assessment of Patient #12’s medical condition. Employees #2 and #3 reported, during interviews conducted from October 28, 2025 through November 6, 2025, that both progress notes completed by Employee #16 and dated 10/26/25 (above), represent the assessment of Patient #12’s medical condition, that no other assessment documentation was available for review at the time of the survey. Patient #15 Document titled “Orders Report” revealed “…Order Date/Time…10/27/25 09:23 AM…Order Description…Urinalysis with Reflex Culture…Order Date/Time…10/27/25 03:41 PM…Order Description…sulfamethoxazole-trimethoprim 800 mg-160 mg (Bactrim DS)…Start Date/Time: 10/27/25 03:40 PM…Stop Date/Time: 11/03/25 03:39 PM…1 tablet BID Two Times Per Day…Order Date/Time…11/3/25 03:53 PM…Order Description Urinalysis with Reflex Culture…. Document titled “Antimicrobial Stewardship Timeout,” dated and timed at 10/30/2025 09:01 AM, revealed “…Current Antibiotics:…Trimethoprim-Sulfa…Does patient have an infection that will respond to antibiotics?...Yes…If so, is the patient on the right antibiotic at the correct dose and route?...Yes…Has a culture been performed and results reviewed, if applicable?...Yes…Electronically Signed by: (Employee #23)….” Request was made for the documentation of the medical provider’s reexamination of Patient #15’s physical status following report of signs of illness. Employees #2 and #3 reported, during interviews conducted from October 28, 2025 through November 6, 2025, that no documentation of a medical provider’s reexamination of Patient #15 was available for review at the time of the survey, that the medical provider “did not physically see the patient.”

rule: R9-10-1302.C.1.c. Administration C. An administrator shall: 1. Ensure that policies and procedures are established, documented, and implemented that: c. Cover patient admission, assessment, treatment plan, transfer, discharge planning, discharge, and recordkeeping;

evidence: Based on review of facility policy and procedure, medical records, observation of facility video monitoring footage, request for facility policies and procedures, and employee interview, the Department determined the Administrator failed to ensure policies and procedures are established, documented, and implemented to cover patient assessments addressing patient falls, patient pain, and monitoring of a patient during an emergency. This deficient practice poses a risk of patient harm, including death, when staff are not aware of assessment procedures directing the provision of medically necessary services for patients.

findings: Facility policy titled “ASSESSMENT OF THE RESIDENT,” Effective Date November 1, 2024, revealed “…C. NURSING SERVICES ASSESSMENT…3. An RN will perform a complete Nursing Assessment annually within the anniversary month of the resident’s admission. An RN’s assessment of the resident’s medical condition is completed in response to resident complaints, including pain, or other physical needs or observations that are reported or detected or any time there is a change in condition….” Medical record for Patient #12 revealed the following care needs: Document titled “Orders Report” revealed “…Order Date/Time…04/14/25 12:10 PM…Other-Nursing…Reason: self-releasing lab belt for wheelchair due to frequent falls…Order Date/Time…09/24/25 11:35 AM…Other-Nursing…Reason: supply resident with care assist button due to high fall risk…Order Date/Time…09/26/25 01:36 PM…Other-Nursing…COMPANION CARE ORDER Due to high fall risk and wheelchair dependence….” Document titled “Physical Examination,” dated 10/02/2025, revealed “…Discussed pain control and the reality of living with chronic pain…Also uses a wheelchair…Has been seeing PT but put on hold after a recent fall…Can resume PT next week as long as no falls…Companion care ordered for transfers, showering, dressing…Long term goal is to prevent falls and minimize pain so he is able to participate in daily activities….” Facility video monitoring footage titled “Indigo Lobby CAM IA.05, dated 10/26/2025, revealed Patient #12 seated in a wheelchair and Employee #9 placing a blood pressure cuff on Patient #12’s left arm at 7:47:42 PM of the video timer, preceding a vitals check. The blood pressure cuff was removed from Patient #12’s left arm at 7:50:54 of the video timer. No other assessment of Patient #12 was observed until paramedics entered the Indigo lobby at 8:13.50 of the video timer. Document titled “Progress Notes,” dated 10/26/25 and timed at 08:35 PM, revealed “…Practitioner: (Employee #9)…Resident came to medical to get his medications and the resident was not…baseline…Vitals were checked with blood pressure of 69/49, Temp, 96.3, pulse of 93, RR of 18, and O2 of 76%...Resident was unable to answer questions…Resident had a decreased LOC…OD was called and gave the order to send the resident out by ambulance…Resident was transported by ambulance to…medical at approximately 2025….” Request was made for facility policies and procedures that cover patient assessments addressing patient care needs including falls, patient pain, and monitoring of a patient during an emergency. None were provided. Employees #1, #2, and #3 confirmed, during interviews conducted from October 28, 2025 through November 6, 2025, that no policies covering patient assessments addressing patient falls, patient pain, and monitoring of a patient during an emergency were available for review at the time of the survey.

rule: R9-10-1302.C.1.n. Administration C. An administrator shall: 1. Ensure that policies and procedures are established, documented, and implemented that: n. Cover medical records, including electronic medical records;

evidence: Based on hospital policy and procedure review, hospital documentation review, patient medical record review, and employee interview, the Department determined that the administrator failed to ensure that Residential Program Specialists (RPS) complete progress note documentation in a timely manner, per hospital policy and procedure. This deficient practice poses a risk of inadequate communication between staff to ensure continuity of care, which poses a threat to the health and safety of patients, including death.

findings: A review of hospital policy titled “Incident Reports,” effective November 25, 2024, revealed: “…Direct care staff will document any occurrence involving a resident or resident-related issues in the appropriate resident health record as follows…if more than one resident is involved, a note must be documented in each resident health record….” A review of hospital policy titled “Documentation Requirements in the Health Record – Admission, Course of Treatment, and Discharge,” effective April 28, 2025, revealed: “…Residential Program Specialists will complete a unit progress note in the approved format on each resident prior to the end of their scheduled shift….” A review of hospital policy titled “Job Description: Residential Program Specialist I,” revealed: “…Job Summary…this position…documents information pertaining to behavioral changes, moods, conversations, reports of physical illness, and objective observations…Job Duties…complies [sic] information, prepares records and documents case files…Knowledge, Skills, and Abilities…Compiling and documenting resident files…Skills in…compiling and documenting resident behavioral health records…Abilities To…Compile and document resident behavior in prescribed format….” A review of hospital policy titled “Job Description: Residential Program Specialist II,” revealed: “…Job Summary…this position…documents information pertaining to behavioral changes, moods, conversations, reports of physical illness, and objective observations…Job Duties…Compiles Information, documents in electronic medical records…Knowledge of…Compiling and documenting resident records…Skills in…Methods and techniques of compiling and documenting resident behavioral health records…Abilities To…Complete and document resident behavior in prescribed format….” A review of hospital policy titled “Position Description: Residential Program Manager,” revealed “…Knowledge…Compiling and documenting resident records…Skill…Methods and techniques of compiling and documenting resident behavioral health records…Ability…Complete and document resident behavior in prescribed format….” A review of patient #3’s hospital documentation, dated 3/7/2025, revealed that patient #3 was involved in a patient-to-patient physical altercation with patient #4. Progress note documentation regarding the incident on 3/7/2025 was not completed by employee #14 until 03/11/2025. A review of patient #4’s hospital documentation, dated 3/7/2025, revealed that patient #4 was involved in a patient-to-patient physical altercation with patient #3. Progress note documentation regarding the incident on 3/7/2025 was not completed by employee #14 until 03/11/2025. A review of patient #10’s hospital documentation, dated 10/16/2025, revealed that patient #10 was involved in financial exploitation by patient #11. Progress note documentation regarding the incident on 10/16/2025 was not completed by employee #16 until 10/19/2025. A review of patient #11’s hospital documentation, dated 10/16/2025, revealed that patient #11 was involved in financial exploitation with patient #10. Progress note documentation regarding the incident on 10/16/2025 was not completed by employee #16 until 10/19/2025. An interview completed with employee #2 on November 4, 2025, confirmed that employee #14 failed to complete progress note documentation for patient #3, and #4, by the end of scheduled shift. An interview completed with employee #2 on November 4, 2025, confirmed that employee #16 failed to complete progress note documentation for patient #10, and #11, by the end of scheduled shift.

rule: R9-10-1305.D.3.c. Personnel Requirements and Records D. An administrator shall ensure that: 3. Personnel members are present on a behavioral health specialized transitional facility ' s premises with the qualifications, skills, and knowledge necessary to: c. Ensure the health and safety of a patient.

evidence: R9-10-1305. Personnel Requirements and Records D. An administrator shall ensure: 3. Personnel members are present on a behavioral health specialized transitional facility’s premises with the qualifications, skills, and knowledge necessary to: c. Ensure the health and safety of a patient. Based on hospital policy and procedure review, primary professional source review, hospital documentation review, hospital video monitoring footage review, patient medical record review and request, employee documentation review, and employee interview, the Department determined that the administrator failed to ensure three nurses (RN(s)) had the skills and knowledge necessary to ensure patient safety in a medical emergency situation. This deficient practice resulted in inadequate assessment of, and delay in, emergency medical response for a patient, which may have contributed to patient death.

findings: A review of hospital policy titled “Job Description: ACPTC Nurse,” revealed: “…Job Summary…responds to…medical emergencies…Job Duties…Provides direct…medical nursing care to residents…observation of…physical status…Knowledge, Skills, and Abilities…Knowledge of…the general principles of medical…nursing…effective communication techniques, both oral and written…Skills in…the assessment of resident’s physical…status…communicating with…nursing staff…and other departments…Abilities to…assess resident’s physical…status…resident’s needs…communicate with…nursing staff…and other departments….” A review of hospital policy titled “Assessment of the Resident,” effective November 1, 2024, revealed: “…An RN’s assessment of the resident’s medical condition is completed in response to resident complaints, including pain, or other physical needs or observations that are reported or detected or anytime there is a change in the resident’s condition….” A review of hospital policy titled “ASH Emergency Operations Plan: 14.2 Medical Emergency – Medical Alert/Code Blue,” effective 7/1/25, revealed: “…14.2.2 Response Procedures Responding to a medical emergency involving a patient Medical Alert…Upon discovery of a patient in need of an emergency medical response, but not requiring cardiopulmonary resuscitation (CPR) or basic life support (BLS) services, staff must immediately…Dial 911 from a Hospital phone or use a radio…State his/her name to the Hospital operator or Security personnel…Announce to the Hospital operator or Security personnel that the emergency is a Medical Alert…Provide the exact location of the medical emergency…Wait for the Hospital operator or Security personnel to repeat the information before breaking the connection…Stay with the patient…The Medical Alert response team (note: the highest ranking medically trained staff member on scene will be the Code Lead) will…Immediately respond with the Medical Emergency Cart to the location of the medical emergency…Assess the patient…Coordinate the delivery of medical care that can be provided on site and within the scope of ASH…Arrange for transport/transfer of the patient to a medical facility, if additional medical care is needed, by calling 911 from the hospital telephone…If transfer is needed, elevate the emergency response to a “Code Blue” and follow the Code Blue procedures, if the medical emergency appears life threatening and requires an emergency medical systems (EMT) response/transport via ambulance…The RN assigned to the Code Team…Brings Emergency Medical Cart to location of medical emergency…If first on the scene, assesses the patient and updates the code response, based on severity of symptoms. If second on scene, notifies RN from patient’s unit and assists with CPR, when necessary…Initiates and notes time when CPR is initiated…Maintains an ongoing record of other interventions, including times of initiation on the Medical Emergency Form…Evaluates the effectiveness of those performing CPR…Documentation and Reporting Requirements for Emergency Medical Care… Medical Emergency Form…The RN assigned to the Code Team will…Initiate the completion of the Medical Emergency form, and sign and date the form upon completion…Forward the completed copy to the Specialty Clinic, after the physician or PNC has signed and dated the form…Forward the ORIGINAL of the Medical Emergency form to Employee Health in the Specialty Clinic, along with the Supervisor’s Report of Injury/Illness, if the medical emergency involved a staff member as a patient….” A review of the National Institutes of Health (NIH) website (2021) revealed: “…Assessment is the first step of the nursing process (and the first Standard of Practice by the American Nurses Association). This standard is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation…Sources of Assessment Data…There are three sources of assessment data: interview, physical examination, and review of laboratory or diagnostic test results…A physical examination is a systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. Inspection is the observation of a client’s anatomical structures. Auscultation is listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope. Palpation is the use of touch to evaluate organs for size, location, or tenderness. Percussion is an advanced physical examination technique typically performed by providers where body parts are tapped with fingers to determine their size and if fluid or air are present. Detailed physical examination procedures of various body systems can be found in the Open RN Nursing Skills, 2e textbook with a head-to-toe checklist in Appendix C. Physical examination also includes the collection and analysis of vital signs…A physical examination can be performed as a comprehensive head-to-toe assessment or as a focused assessment related to a particular condition or problem. Assessment data is documented in the client’s medical record, either in their electronic medical record (EMR) or their paper chart, depending upon agency policies and procedures….” A review of hospital documentation, dated 10/26/2025, revealed that on 10/26/2025, patient #12 did not appear well and was brought to Indigo medical unit. Nurses at Indigo medical unit assessed patient #12 and determined that patient #12’s vital signs were abnormal and called the paramedics for emergency medical assistance. Paramedics arrived and transported patient #12 to (off-site medical emergency department) on 10/26/2025. A review of patient #12’s hospital video monitoring footage titled “Indigo Lobby CAM IA.05,” dated 10/26/2025, from 7:43:38 PM to 8:18:46 PM, revealed at 7:45:15 PM, patient #12 was brought to the Indigo medical unit. At 7:46:56 PM, employee #9 entered the room and took patient #12’s vital signs. At 7:49:09 PM, employee #5 entered the room, and left at 7:50:53 PM. At 7:50:53 PM, employee #9 removed the cuff band from patient #12’s arm and wrote on a piece of paper. At 7:51:37 PM, employee #9 left the room, and re-entered at 7:59:46 PM. At 8:01:48 PM, employee #7 entered the Indigo medical unit and left to another room with employee #5, and #9. Employee #3 confirmed that employee #7 assisted employee #5, and #9 with making a call to 911. At 8:13:50 PM, paramedics arrived, and left with patient #12 at 8:18:46 PM. A request was made for a nursing assessment for patient #12’s change of condition. None was provided during the survey. A request was made for patient #12’s medical emergency form. None was provided during the survey. An email dated October 26, 2025, from employee #16 stated: "... patient #12 has been having NVD (Nausea, Vomiting, Diarrhea) the last few days. I believe today patient #12 is coming out if it but this morning patient #12 came for meds (missed the previous 2 morning meds) and patient #12 was quite dramatic about patient #12’s) feelings of distress...." Employee #16 writes "...patient #12 wanted to be sent to ED and I told patient #12 no, not necessary...." An interview with employee #5, completed on October 30, 2025, revealed: "...there are issues with the way PNCs (Psychiatric Nurse Coordinator) and ODs (Off-Duty Provider) handle things...they don't show up for code and drop F-bombs, asking why they should go for code...we get screamed and yelled at by the OD...throughout the years I've been working here...we try not to get them involved if we don't have to, because of their attitude...." An interview with employee #9, completed on November 4, 2025, confirmed that a neither a medical alert code, nor a code blue was called for patient #12 on October 26, 2025. Employee #9 confirmed that any staff can call a code anywhere on campus if they encounter a patient appearing with a medical emergency. Employee #9 confirmed that a change of status for patient #12 was not communicated among Indigo medical unit staff.

rule: R9-10-1313.B.2. Medications Services B. If a behavioral health specialized transitional facility provides medication administration, a medical director shall ensure that: 2. A patient ' s refusal to take prescribed medication is documented in the patient ' s medical record;

evidence: Based on facility policy and procedure, medical records, medical record request, and employee interview, the Department determined the Administrator failed to ensure a patient medication administration refusal was documented within the patient medical record pursuant to facility policy. This deficient practice poses the risk that a patient’s medical personnel are not aware of a medication administration refusal and the potential for patient harm if medical risk factors are not addressed subsequent to the medication refusal.

findings: Policy titled “Medication Services,” Effective Date November 1, 2024, revealed “…D. Post-Administration Duties…2. Medication refusals must be communicated to the Psychiatric Nurse Unit Manager (PNUM) and the prescribing BHMP by the next work day. In cases where refusals require a more immediate notification, the on-duty physician shall be notified….” Medical record for Patient #12 revealed the following: Document titled “eMAR,” dated 10/2025, revealed the following medication refusals: Alendronate 70 MG Tablet, refused 10/24/2025, 0800 Cholecalciferol 1000 Units Tablet, refused 10/24/2025, 0700 Loratadine 10 MG Tablet, refused 10/24/2025, 0700 Losartan 25 MG Tablet, refused 10/24/2025, 0700 Metformin 500 MG Tablet, refused 10/24/2025, 0700 Montelukast 10 MG Tablet, refused 10/24/2025, 0700 Multivitamin-Minerals NA Tablet, refused 10/24/2025, 0700 Naproxen 250 MG Tablet, refused 10/24/2025, 1900 Omeprazole 20 MG Capsule, refused 10/24/2025, 0700 Pregabalin 100 MG Capsule, refused 10/24/2025, 2000 Tamsulosin 0.4 MG Capsule, refused 10/24/2025, 0700 Bupropion HCL ER 24-Hour 150 MG Tablet, refused 10/24/2025, 0700 Sertraline 100 MG Tablet, refused 10/24/2025, 0700 Latanoprost 0.005% Solution Ophthalmic, refused 10/24/2025, 2000 Document titled “Daily Medication Refusals” revealed “…Medication nurse is required to complete this form in addition to the required documentation in the health record during medication administration to note any refusals….” Document headings included “…Unit…Date…Time…Resident Name…Medication Refused…Actions taken/Nurses Initials (S.O.A.P. Note in health record completed)…Physician’s/Medical Provider’s acknowledgement/action (Initial)…* Keep Trying…* Discontinue Med/Test…Notify Tx Team…” Request was made for the Daily Medication Refusal form for Patient #12 for 10/24/2025. None was provided. Employees #1 and #2 confirmed during interviews conducted October 28, 2025 through November 5, 2025, that no medical record document titled Daily Medication Refusal or documentation verifying medication refusals were communicated to the physician/medical provider and PNUM for Patient #12’s medication refusals on October 24, 2025 were available for review at the time of the survey.

rule: R9-10-1315.A.5. Emergency and Safety Standards A. A medical director shall ensure that policies and procedures for providing medical emergency treatment to a patient are established, documented, and implemented and include: 5. A method for ensuring a patient may be transported to a hospital or other health care institution to receive treatment for a medical emergency that the behavioral health specialized transitional facility is not able or authorized to provide.

evidence: R9-10-1315. Emergency and Safety Standards A. A medical director shall ensure that policies and procedures for providing medical emergency treatment to a patient are established, documented, and implemented and include: 5. A method for ensuring a patient may be transported to a hospital or other health care institution to receive treatment for a medical emergency that the behavioral health specialized transitional facility is not able or not authorized to provide. Based on hospital policy and procedure review, hospital documentation review, hospital video monitoring footage review, and employee interview, the Department determined that the administrator failed to ensure that staff followed hospital policy and procedure related to ensuring a patient was transported via 911 call/ambulance to receive emergency medical treatment at another hospital. This deficient practice resulted in a delay in emergency medical treatment, which may have contributed to patient death.

findings: A review of hospital policy titled “ASH Emergency Operations Plan: 14.2 Medical Emergency – Medical Alert/Code Blue,” effective 7/1/25, revealed: “…14.2.2 Response Procedures…Responding to a medical emergency involving a patient…Medical Alert…Upon discovery of a patient in need of an emergency medical response, but not requiring cardiopulmonary resuscitation (CPR) or basic life support (BLS) services, staff must immediately…Dial 911 from a Hospital phone or use a radio…State his/her name to the Hospital operator or Security personnel…Announce to the Hospital operator or Security personnel that the emergency is a Medical Alert…Provide the exact location of the medical emergency…Wait for the Hospital operator or Security personnel to repeat the information before breaking the connection…The Medical Alert response team…will…Immediately respond with the Medical Emergency Cart to the location of the medical emergency…Assess the patient…Coordinate the delivery of medical care that can be provided on site and within the scope of ASH…Arrange for transport/transfer of the patient to a medical facility, if additional medical care is needed, by calling 911 from the hospital telephone…If transfer is needed, elevate the emergency response to a Code Blue and follow the Code Blue procedures, if the medical emergency appears life threatening and requires an emergency medical systems (EMT) response/transport via ambulance…The Hospital Operator…Notifies Hospital Security personnel of the incoming ambulance/EMS traffic…During regular business office hours, notifies by cell phone all psychiatry and primary care staff, including the medical Officer of the Day…This communication will include the type of alert and the location of the code…IF the code occurs outside of regular business hours, pages/calls the On-Call provider after activation of the response team….” A review of patient #12’s hospital documentation, dated 10/26/2025, revealed that security staff was contacted by operator staff at 7:56 PM, requesting assistance to call 911, as he/she did not know how to make a call to 911. The Cholla control unit made an additional radio call to security staff, requesting assistance to call 911. Security staff was made aware that staff at Indigo medical unit spoke with paramedics, but did not call a code. Security staff were directed to escort paramedics. Upon arrival of security staff at 8:01 PM, nursing staff reported patient #12 was unresponsive, and attempted to call paramedics on their internal phone line, but was not able to be transferred out when dialing zero or 911, and no calls had been successfully made to 911 at that point. Security staff called operator staff again, requesting that a conference call be made with 911. Operator staff repeated they were not sure how to make the conference call with 911. Nursing staff was advised by security staff to instead contact 911 with a personal cell phone. 911 contact call was completed at 8:09 PM. Paramedics arrived at the Indigo medical unit at 8:14 PM. Nurse Coordinator staff also arrived at the Indigo medical unit at 8:14 PM. Patient #12 was transported via ambulance to (off-site medical emergency department) at 8:31 PM. A review of patient #12’s hospital video monitoring footage titled “Indigo Lobby CAM IA.05,” dated 10/26/2025, from 7:43:38 PM to 8:18:46 PM, revealed at 7:59:16 PM that employee #13 made a call. Employee #3 confirmed employee #13 was contacting the operator staff to make a call to 911. At 8:02:12 PM, employee #7 arrived at Indigo medical unit. At 8:03:13 PM, employee #7 met with employee #5, and #9 in another room. Employee #3 confirmed that at this time, employee #7 assisted employee #5, and #9 in making a call to 911. At 8:05:16 PM, employee #7 left Indigo medical unit and returned at 8:09:43 PM. At 8:10:45 PM, employee #7 left and returned with paramedics at 8:13:50 PM. At 8:18:46, patient #12 left Indigo medical unit with paramedics. An interview with employee #7, completed on 10/31/2025, confirmed that between 7:50 PM and 7:55 PM, he/she received a call from the operator staff for assistance, and asked “…are you ok…? Operator staff responded “…yes and no….” Employee #7 confirmed he/she went to the operator unit and was informed that a nurse from Indigo medical unit needs 911 assistance, stating “…I don’t know how to call 911….” Employee #7 confirmed that the operator staff returned to the nurse that was requesting assistance, and was told that the nurses made a call to 911 and paramedics were en route. Employee #7 stated “...they were operating as a code blue without code being called….” Employee #7 confirmed that he/she went to the Indigo medical unit to assist the operator staff. Employee #7 confirmed that he/she told employee #5, and #9 that 911 was on the way, and employee #5 replied “…no they’re not….” Employee #7 confirmed he/she went to the unit phone and directed the operator staff to make a call to 911. Employee #7 confirmed that operator staff paused, and employee #7 asked the operator staff “…do you know what you’re doing…?” in which the operator staff replied “…no, not really….” Employee #7 confirmed that he/she then advised Indigo medical unit nurses “…I’m sorry, but you need to use your phone now…,” and a call to 911 was made. Employee #7 stated “…it was nine counted minutes of contributed delay….”

rule: R9-10-1315.B. Emergency and Safety Standards B. An administrator shall ensure that medical emergency treatment is provided to a patient admitted to the behavioral health specialized transitional facility according to the behavioral health specialized transitional facility ' s policies and procedures.

evidence: Based on facility policy and procedure review, observation of facility video monitoring footage, medical record review, facility document review, document request, and employee interviews, the Department determined the Administrator failed to ensure facility policy was implemented in order to protect the safety of a patient during a medical emergency. This deficient practice contributed to the death of a patient when failure to call a medical emergency code led to a delay in emergency personnel response.

findings: Facility policy titled “14.2 Medical Emergency – Medical Alert/Code Blue,” Effective: 7/1/25, revealed “…14.2.2 Response Procedures…Responding to a medical emergency involving a patient…Medical Alert…Upon discovery of a patient in need of an emergency medical response, but not requiring cardiopulmonary resuscitation (CPR) or basic life support (BLS) services, staff must immediately…Dial 911 from a Hospital phone or use a radio…State his/her name to the Hospital operator or Security personnel…Announce to the Hospital operator or Security personnel that the emergency is a Medical Alert…Provide the exact location of the medical emergency…Wait for the Hospital operator or Security personnel to repeat the information before breaking the connection…The Medical Alert response team…will:…Immediately respond with the Medical Emergency Cart to the location of the medical emergency…Assess the patient…Coordinate the delivery of medical care that can be provided on site and within the scope of ASH…Arrange for transport/transfer of the patient to a medical facility, if additional medical care is needed, by calling 911 from the hospital telephone…If transfer is needed, elevate the emergency response to a Code Blue and follow the Code Blue procedures, if the medical emergency appears life threatening and requires an emergency medical systems (EMT) response/transport via ambulance… …14.2.3. Staff Responsibilities and Training…Medical Alert/Code Blue Response Team Members must complete training that is applicable to the roles assigned to them for the medical emergency response… …The Psychiatric Nurse Coordinator (PNC) assigns specific RNs to be on the “Code Team” at the start of each shift…The Psychiatric Nurse Practitioner (PNC) will respond to all Medical Alert and Code Blue emergency codes…They will provide support in whatever way necessary during the event… …The RN assigned to the Code Team:…Brings Emergency Medical Cart to location of medical emergency…If first on the scene, assess the patient and updates the code response, based on the severity of symptoms…If second on scene, notifies RN from patient’s unit and assists with CPR, when necessary…Maintains an ongoing record of other interventions, including times of initiation on the Medical Emergency Form… …The physician/medical provider:…Will assume the role of Code Lead upon arrival on scene…If first on the scene, assesses the patient and updates the code response, based on severity of symptoms (if the Medical Alert or Code Blue occurs outside of normal business hours, this decision will be made by the PNC…)…If EMS is not already contacted and responding, determines if the patient needs to be transported offsite by ambulance (if the Medical Alert or Code Blue occurs outside of normal business hours, this decision will be made by the PNC…)...Facilitates discussion with emergency response code team members to critique the process of events and identify any possible opportunities for improvement…Initiates direct emergency orders… …Security will:… Provide EMS with direction to the site of the Code and remain available to assist with managing doors, movement of patients/staff (crowd control) and/or assisting with CPR as necessary… …The Hospital Operator…Notifies Hospital Security personnel of the incoming ambulance/EMS traffic…During regular business office hours, notifies by cell phone all psychiatry and primary care staff, including the medical Officer of the Day…This communication will include the type of alert and the location of the code…IF the code occurs outside of regular business hours, pages/calls the On-Call provider after activation of the response team… …Documentation and Reporting Requirements for Emergency Medical Care…Medical Emergency Form… The RN assigned to the Code Team will:…Initiate the completion of the Medical Emergency form, and sign and date the form upon completion…Forward the completed copy to the Specialty Clinic, after the physician or PNC has signed and dated the form…Medical Emergency Critique Form…The PNC will complete the Medical Emergency Critique form, and sign and date the completed form…The form is to be maintained in the Staffing/PNC Office…On an Ad hoc basis, an interdisciplinary team will meet to identify and suggest practice and system improvements in resuscitative performance…The interdisciplinary team includes the Chief Medical Officer (CMO), Chief Nursing Officer (CNO) and other clinical department representatives, as determined necessary and relevant to the incident under review….” Facility video monitoring footage titled “Indigo Lobby CAM IA.05,” dated 10/26/2025, revealed Patient #12 seated in a wheelchair and Employee #9 placing a blood pressure cuff on Patient #12’s left arm at 7:47:42 PM of the video timer, preceding a vitals check. The blood pressure cuff was removed from Patient #12’s left arm at 7:50:54 PM of the video timer. No other assessment of, or intervention for, Patient #12 was observed until paramedics entered the Indigo lobby at 8:13.51 PM of the video timer. Facility video monitoring footage titled “Indigo Lobby CAM IA.05,” dated 10/26/25, further revealed PNC (Employee #22) entering the Indigo lobby at 8:14:09 PM of the video timer. No physician or medical provider was observed present in the Indigo lobby during the duration of the video footage. Medical record document, for Patient #12, titled “Progress Notes,” dated 10/26/25 and timed at 08:35 PM, revealed “…Practitioner: (Employee #9)…Resident came to medical to get his medications and the resident was not…baseline…Vitals were checked with blood pressure of 69/49, Temp, 96.3, pulse of 93, RR of 18, and O2 of 76%...." Facility documentation for Patient #12, dated 10/26/2025, revealed “…At approximately 1957 hours, (Employee #7) spoke with (Employee #19) who advised (he/she) received a request from …Medical Staff to be connected with 911 for paramedics…As (he/she) was explaining, (Employee #7) received an additional radio call from (Employee #20) requesting an emergency phone call…(Employee 7) contacted (Officer #20) who then advised that (employees) at…Medical had contacted Paramedics and they were on their way…(Employee #7) asked (Employee #20) “They spoke with paramedics, and they didn’t call a code?”…(He/she) stated yes and confirmed no code was called….” Request was made for the Medical Emergency Form and the Medical Critique Form, pursuant to facility policy, associated with the medical emergency involving Patient #12 on 10/26/2025. None was provided. Employee #7 confirmed, during an interview on 10/31/2025 at 1:00 PM, “…This would’ve absolutely been a reason to call a code…regardless of where the patient is at, they call a code if the patient needs services, no matter what….” Employee #8 confirmed, during an interview on November 4, 2025 at 11:25 AM, “…If there’s a medical issue, you call a code….” Employees #1 and #3 confirmed, during interviews conducted from October 28, 2025 through November 6, 2025, that no medical code was called for Patient #12, during the medical emergency documented on 10/26/2025. Employees #1 and #3 also confirmed neither a Medical Emergency Form nor a Medical Critique Form were completed following the response to the medical emergency on 10/26/2025. Pursuant to facility video monitoring footage titled “Indigo Lobby CAM IA.05,” dated 10/26/2025,” no further assessment of, or intervention for, Patient #12 appeared to have occurred between the vitals check and arrival of paramedics, no physician or medical provider was observed present in the Indigo lobby during the duration of the video footage, and the PNC entered the Indigo lobby at 8:14:09 PM of the video timer.


summary: Complaint - 5/20/2025 - 5/21/2025

raw_content:
The following deficiencies were cited at the time of the unannounced, on-site State Complaint Investigation Survey conducted from May 20, 2025 to May 21, 2025, pursuant to the rules found in Arizona Administrative Code (A.A.C.) Title 9, Chapter 10, Article 13- Behavioral Health Specialized Transitional Facility, for the following case numbers:

00130476
00129794
00124528
00124525

Healthcare Compliance Officers
May 23, 2025

rule: R9-10-1302.C.1.a. Administration C. An administrator shall: 1. Ensure that policies and procedures are established, documented, and implemented that: a. Include job descriptions, duties, and qualifications including required skills, knowledge, education, and experience for employees, volunteers, and students;

evidence: Based on review of Hospital documents, document request, patient medical record and employee interview, the Department determined the Administrator failed to ensure an employee job description was updated to reflect current position expectations. This deficient practice poses the potential risk that employees will not be aware of their position responsibilities, adversely impacting patient care.

findings: Hospital document/email titled “ACPTC Resident Care” date/time of May 5, 2025 at 2:46 PM, authored by Employee #3, revealed “… To clarify expectations, please find the attached Position Descriptions for the RPS series. You will find the following statements under Job Summary: "provides for the care of residents through guidance on and assistance as needed with activities of daily living (ADLs) including assisting residents with personal hygiene; environmental hygiene including cleaning of rooms, changing of bedding and washing of linens as needed; assists infirm residents in walking/transferring; assists non-ambulatory and handicapped residents with hygiene needs (showering, changing) as needed, assists handicapped residents with feeding as directed; lift and reposition residents as needed." You will also find the following statement under Job Duties: "Provides for the care of residents through guidance on and assistance as needed with activities of daily living (ADLs) including assisting residents with personal hygiene, other duties as assigned as related to the position." Hospital document titled “JOB DESCRIPTION,” including “Job Classification: RESIDENTIAL PROGRAM SPECIALIST 1,” signed by Employee #11 on “12-2-24,” revealed no documentation of position description expectations as identified in the above-noted Hospital document/email. Request was made for Hospital policy regarding completion/updating of employee job descriptions. None was provided. Employee #3 confirmed the job description noted above for Employee #11 is the most current in the employee’s personnel file, verified that it does not include documentation of position description expectations as identified in the Hospital document/email authored by Employee #3 and confirmed the facility has no policy referencing job descriptions.