summary: Complaint - 12/29/2025

raw_content: The following deficiency was found during the on-site  investigation of complaint 00154338 conducted on December 29, 2025:

rule: R9-10-706.G.3.e. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: e. The individual's compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;

evidence: Based on record review, documentation review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's compliance with requirements in A.R.S. §§ 36-425.03, for one of ten personnel records sampled. The deficient practice posed a risk if E11 was a danger to a vulnerable population.

findings: 1. A review of E11's personnel record revealed a fingerprint clearance card. However, the fingerprint clearance card expired on July 22, 2025. 2. A review of the Department of Public Safety Fingerprint Verification website revealed E11's fingerprint clearance card was not valid. 3. In an exit interview, E1 and E2 acknowledged E11's fingerprint clearance card had expired, was not valid and had not been renewed.


state: AZ

facility_name: EMOTICARE RIMROCK, LLC

summary: Complaint - 12/15/2025

raw_content: No deficiencies were found during the on-site investigation of complaint 00152064 conducted on December 15, 2025.

inspection_type: Complaint


summary: Complaint - 11/19/2025

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00150788 conducted on November 19, 2025.

rule: R9-10-703.G.2. Administration G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a self-injury or has an accident that requires immediate intervention by an emergency medical services provider.

evidence: Based on documentation review and interview, the administrator failed to report self-injury within two working days after a resident inflicted a self-injury. The deficient practice posed a safety risk as the Department was unable to assess if there was an immediate health and safety concern for the other residents residing in the behavioral health residential facility.

findings: 1. A documentation review of the facility's incident reports revealed a document titled "Incident Report" that occurred on October 11, 2025. The incident report stated that R5 "....expressing suicidal and homicidal ideations and made an attempt at self harm by cratching her arm with a rock. with the client's level of panic and anxiety it was determined by staff that [R5] would be transported to VVMC for further psychiatric evaluation. at approximately 6:45 PM Client [R5] was transported to inpatient care at VVVMC. Client was checked into VVMC for further evaluation and returned campus the following morning (10/12)". 2. A review of the facility's policies and procedures revealed a policy titled "Policies and Procedures for Incident Reporting". The section titled "Procedures" stated "n. The Executive Director will provide written notification to the Arizona Department of Health Services Bureau of Residential Facilities of a resident's death and a report of Self-Injury within two working days after the resident inflicts a self-injury or has an accident that requires immediate intervention by and emergency medical services provider." 3. In an interview, E1 reported not understanding what needed to be reported to the Department. E2 reported resident's have minor self-harm actions every day and would require the facility to constantly be contacting the department. 4. In an exit interview with E1 and E2, the findings were reviewed. No additional comments or documents were provided.

rule: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

evidence: Based on documentation review and interview, the administrator failed to ensure a resident is treated with dignity, respect, and consideration. The deficient practice posed a safety risk as residents in the home have experienced life events, making them vulnerable to inappropriate behaviors by staff.

findings: 1. A documentation review of the facility's incident reports revealed a document titled "Incident Report" that occurred on October 19, 2025. The incident report revealed that the guardians of R1 called the facility to complain about the behavior of E5. R1's guardians reported that E5 made sexual and racial jokes to R1. The incident report also indicated that R1’s guardian expressed anger, stating the event was “triggering” and could be perceived as “grooming,” due to the guardian’s own history as a victim. 2. A documentation review of a document titled "Employee Verbal Warning - Professional Boundaries" revealed E5 had received a verbal warning on October 28, 2025. The Summary reported E5 met with E2 to discuss the importance of professionalism and maintaining appropriate boundaries with residents. The section titled "Next Steps" reported that no further action is required. E5 is to be monitored to ensure compliance and ongoing professional development occurs. 3. In an interview, E1 and E2 reported the situation had been addressed with E5. E1 reported if the behaviors continue, the necessary action will be taken, but no issues have occurred since the date of the incident. 4. In an exit interview, the findings were reviewed with E1 and E2. No additional comments or documents were provided.


summary: Complaint - 9/8/2025

raw_content: No deficiencies were found during the on-site investigation of complaint 00143241 conducted on September 8, 2025.


summary: Compliance (Initial) - 2/3/2025

raw_content: No deficiencies were found during the on-site initial inspection conducted on February 3, 2025.

inspection_type: Compliance (Initial)


facility_name: CONNECTED HEARTS LLC - BHRF

summary: Compliance (Annual) - 1/7/2026

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on January 7, 2026:

inspection_type: Compliance (Annual)

rule: A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

evidence: Based on record review and interview, the administrator failed to ensure the healthcare institution administered a training program for all staff regarding fall prevention and fall recovery that included the initial training and continued competency training in fall prevention and fall recovery, for one of four personnel sampled. The deficient practice poses a safety risk if staff were not trained to assist residents in an emergency.

findings: 1. A review of E3's personnel records revealed no evidence of initial training and continued competency training in fall prevention and fall recovery. 2. In an interview, E1 and E2 reported E3 completed fall prevention and fall recovery training; however, E1 and E2 could not locate the documentation. 3. In an exit interview, the findings were reviewed with E1 and E2, and no further documentation or comment was provided.

rule: R9-10-706.G.3.c. Personnel G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: c. The individual's completed orientation and in-service education as required by policies and procedures;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed orientation as required by policies and procedures, for one of four sampled personnel members. The deficient practice posed a safety risk if E3 were unable to meet the needs of the residents.

findings: 1. Arizona Administrative Code (A.A.C.) R9-10-101.155. states "Orientation" means "the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution." 2. A review of facility documentation revealed a policy and procedure titled "Personnel Orientation" dated August 26, 2024. The policy stated "BHRF personnel members are required to complete an orientation and demonstrate competency in providing general resident care and services prior to working independently with residents." 3. A review of E3's personnel record revealed E3 had no documentation of a completed orientation. 4. A review of R1's medical record revealed a treatment plan dated in 2025. The treatment plan was completed by E3. 5. In an interview, E1 and E2 reported E3 completed orientation for the facility; however, E1 and E2 could not locate the completed orientation. 6. In an exit interview, the findings were reviewed with E1 and E2, and no further documentation or comments were provided

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained to include documentation of Arizona Revised Statutes (A.R.S.) § 36-411(C)(1) and documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) § 36-425.03(E), for one of four personnel members sampled. The deficient practice posed a risk if E3 were a danger to a vulnerable population.

findings: A.R.S. § 36-411(C)(1) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency." A.R.S. § 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 E3’s personnel record revealed a valid fingerprint clearance card, however, documentation of compliance with A.R.S. § 36-425.03(E) was not available for review. 2. In an interview, E1 reported E1 contacted E3's previous employers, per A.R.S. § 36-411(C)(1), and E3 had completed the requirements in A.R.S. § 36-425.03(E); however, E1 could not locate the documentation. 3. In an exit interview, the findings were reviewed with E1 and E2, and further documentation or comment was not provided.


summary: Initial Monitoring - 5/6/2025

raw_content: No deficiencies were found during the on-site abbreviated inspection conducted on May 6, 2025.

inspection_type: Initial Monitoring


summary: Compliance (Initial) - 1/17/2025 - 1/21/2025

raw_content: No deficiencies were found during the on-site initial inspection conducted on January 17, 2025 and the off-site documentation review completed on January 21, 2025.


facility_name: FORWARD IN LIFE II

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

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on February 13, 2026:

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained to include documentation of the individual's compliance with the requirements in Arizona Revised Statutes (A.R.S.) § 36-425.03(E), for one of six personnel members sampled. The deficient practice posed a risk if E6 was a danger to a vulnerable population.

findings: A.R.S. § 36-425.03(E) 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 personnel record revealed E6 was hired as a behavioral health technician. E6's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. § 36-425.03(E) was not available for review. 2. In an interview, E5 reported E6 did not complete the forms required by A.R.S. § 36-425.03(E); however, E6 was going to complete the forms. 3. In an exit interview, the findings were reviewed with E5, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-716.A.7.a. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, 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 have access to any materials that may present a threat to the resident's health or safety based on the resident’s treatment needs, developmental level and personal history. The deficient practice posed a risk as R2 gained access to an electronic cigarette while admitted into a behavioral health residential facility for individuals under 18 years of age.

findings: 1. A review of Department documentation revealed the facility was licensed as a behavioral health residential facility to provide services to individuals under 18 years of age. 2. A review of R2’s medical record revealed a behavioral health assessment titled “Assessment Intake MH (Residential).” The assessment stated, “… The client reported smoking 1-2 times weekly. First use of a Vaporizer Pen was at 14 years old. 5 hits daily. … Daily use until [R2] got on probation, then [R2] was clean for 6 months.” 3. A review of R2’s medical record revealed a document titled “Child and Family Team (Residential)” (dated January 2026). The document stated, “… [R2] was discovered with a lighter and a Vaporizer…” 4. A review of R2's medical record revealed a document titled "Individual Therapy (Residential)" (dated in January 2026). The document stated, "… During the client coordination of care and staffing, [E5] the Program Manager, reported that [R2] was discovered with a Vaporizer for smoking in the house.” 5. A review of R2's medical record revealed a document titled "Individual Therapy (Residential)" (dated in February 2026). The document stated, "… To address staff concerns, [R2] shared that the vaporizer was not [R2’s] and that [R2] did not bring it home from school … [R2] brought a vaporizer home which led to the other [residents] getting their hands on it.” 6. In an interview, E5 reported R2 reported R2 was able to get a vape pen from R2’s parent’s house. E5 reported R2’s parent was aware of R2 having a vape pen. E5 reported R2 was caught with a vape pen at school. 7. In an exit interview, the findings were reviewed with E5, and no additional comments, statements, or documentation were provided regarding the findings.


summary: Complaint;Initial Monitoring - 9/24/2025

raw_content: The following deficiencies were found during the on-site abbreviated follow-up inspection and investigation of complaints 00145691, 00145942, and 00145693 conducted on September 24, 2025:

inspection_type: Complaint;Initial Monitoring

rule: R9-10-703.C.1.e.i-iv. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: e. Cover cardiopulmonary resuscitation training including: i. The method and content of cardiopulmonary resuscitation training, which includes a demonstration of the individual's ability to perform cardiopulmonary resuscitation; ii. The qualifications for an individual to provide cardiopulmonary resuscitation training; iii. The time-frame for renewal of cardiopulmonary resuscitation training; and iv. The documentation that verifies that the individual has received cardiopulmonary resuscitation training;

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure that policies and procedures were implemented to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training including the qualifications for an individual to provide cardiopulmonary resuscitation training, for one of six records sampled. The deficient practice posed a risk if the personnel member was unable to perform CPR.

findings: 1. A review of E5's (hired as a behavioral health technician) personnel record revealed a CPR/AED/First-Aid certificate of completion from NationalCPRFoundation. 2. A review of facility documentation revealed a "Policies and Procedures Manual." The "First Aid and CPR Training" policy stated, "Policy Statement: In order to keep first aid and CPR training and skills up to date it is required that each personnel member provide the following: ... Method and content of adult and pediatric CPR training which includes the ability to perform and demonstrate cardio pulmonary resuscitation, only if the card is not issued by: American Red Cross, American Heart Association, or National Safety Council..." 3. A review of the "NationalCPRFoundation" website revealed courses were conducted online. The "NationalCPRFoundation" website stated the following: -"Help Save Lives Today with Your Online CPR Certification Training!" -"All courses can be completed online in just a few hours or less. Once you have completed an examination via our quick and easy online system, you will receive a PDF copy of your certificate immediately via email as well as your card within 2-5 business days;" and -"Online training is a legal and acceptable form of training, however, NCPRF® does not offer in-person training. Your employer or licensing board may require in-person training for "special industries". You should consult with your employer if you have questions about whether our certification will be accepted. Therefore, we cannot guarantee that our certification will be accepted in every situation." 4. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-703.C.2.t. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: t. Cover how the behavioral health residential facility will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure policies and procedures were implemented to protect the health and safety of a resident, to cover how the behavioral health residential facility will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual, for one of one record sampled. The deficient practice posed a risk as the standards expected of employees in the policies and procedures were not followed.

findings: 1. A review of facility documentation revealed a "Report of Unusual Occurrence" for R1 dated in 2025 at 03:25 PM. The report detailed a verbal and physical altercation between R1 and E5 (hired as a behavioral health technician), with E6 (hired as a group home manager and behavioral health technician) as a witness. The report stated, -"The nature and extent of the adult's vulnerability [in the alleged or suspected abuse, neglect or exploitation]: Suspected child abuse, consisting of staff slapped, kicked and punched client." -"The nature and extent of the adult's child injuries or physical neglect or of the exploitation of the adult's child property [include changes to the resident's physical, cognitive, functional, or emotional condition]: Client has scratches on arms and a welt mark across [R1's] face. Client was crying, client stated [R1] was okay after [R1] was asked multiple times. EMS also checked [R1] and checked vitals and stated everything is normal." -"Name of individuals involved [in the alleged or suspected abuse, neglect or exploitation]: [E5]" -"Name if witnesses [the alleged or suspected abuse, neglect or exploitation]: [E6]" -"Action taken by the facility [in the alleged or suspected abuse, neglect or exploitation]: Called 911, EMS, DCS, Guardians, DHS, Follow-Up PCP Appt. Follow-up appt made for psych. Crisis team also arrived and spoke to client." -"Action taken by the facility [to prevent reoccurrence of such event]: Immediate termination, providing staff additional trainings." 2. A review of facility documentation revealed a written account of the incident. The document stated, "At approximately 3:25 p.m., the client was in the office and directed inappropriate language toward the staff, calling them derogatory names. In response, staff made inappropriate remarks toward the client. The client became upset and told staff to stop making comments about [R1's] mother or [R1] would become physical. Staff then challenged the client, at which point the client lunged towards staff and struck [E5] in the head. Staff raised [their], slapped the client and began punching [R1] with a closed fist. The client asked the staff to stop and get away. Staff eventually stopped; however, the client continued using profanity, kicked the staff, and pulled [E5's] hair. Staff then became more aggressive by grabbing and hitting the client again. Once the altercation ended, the house manager instructed staff to leave the office. Staff walked out, then returned briefly to gather [their] belongings. The client told staff [E5] would be reported for abuse, to which staff replied inappropriately. The house manager again directed staff to leave, and staff complied. The group home manager notified [E1] of the incident, and [E1] made the necessary calls. The group home manager assessed the client's injuries. Police and the fire department were also notified and arrived to assess the client. During the altercation, the group home manager attempted to intervene but was unable to de-escalate due to the continuous back-and-forth between staff and client." 3. While the Compliance Officer was on-site, E1 emailed E6 a termination letter. 4. A review of facility documentation revealed a "Policies and Procedures Manual." The "Respond to Out of Control Behavior, Threats/Duty Warn/Emergency Safety Response" policy stated, "A resident in the midst of a mental health crisis cannot always communicate their thoughts, feelings, or emotions clearly. They may find it difficult to understand what others are saying. It is important to emphasize with the person's feelings, stay calm, and try to de-escalate the crisis... 4). Avoid overreacting. Keep your voice calm, relax, and use a warm, friendly and slow demeanor; do not make sudden movement; do not touch the resident unless invited to do so; do not overreact; do not criticize.... 8) Avoid arguing, coercing, insisting, or reasoning with the resident. Do not challenge them. Explaining your actions may reassure someone who who's having irrational thoughts. Express support and concern. Ask how you can help." 5. The Compliance Officer observed video footage of the incident. In the video, E5 and E6 are in the privacy room (15:13:54-15:14:36). R1 is not in the room and was heard yelling; however, R1's statements are incomprehensible. R1 came to the privacy room door and words were exchanged between E5 and R1 (15:14:37). R1 enters the room and pushes E5 (15:15:44). E5 pushes R1, grabs and holds their arm, slaps them twice (15:14:45 to 15:14:48). E5 puts R1 on the ground by holding one of their arms and their head, and then was crouched over them (15:14:49-15:16:00). E5 rolls R1 over and keeps their hand on R1 (15:16:01-15:16:11). E5 lifts R1's back off the ground using both hands (15:16:18). E5 slaps R1 eight times and kicks them once (15:16:39-15:16:45). E5 exits the room at 15:19:50 while E6 remains in the room with R1. 6. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-706.B.3.c. Personnel B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to: c. Ensure the health and safety of a resident.

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure that sufficient personnel members were present on a behavioral health facility's premise with the skills and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as a personnel member

findings: 1. A review of facility documentation revealed a "Report of Unusual Occurrence" for R1 dated September 22, 2025, at 03:25 PM. The report detailed a verbal and physical altercation between R1 and E5 (hired as a behavioral health technician), with E6 (hired as a group home manager and behavioral health technician) as a witness. The report stated, -"The nature and extent of the adult's vulnerability [in the alleged or suspected abuse, neglect or exploitation]: Suspected child abuse, consisting of staff slapped, kicked and punched client." -"The nature and extent of the adult's child injuries or physical neglect or of the exploitation of the adult's child property [include changes to the resident's physical, cognitive, functional, or emotional condition]: Client has scratches on arms and a welt mark across [R1's] face. Client was crying, client stated [R1] was okay after [R1] was asked multiple times. EMS also checked [R1] and checked vitals and stated everything is normal." -"Name of individuals involved [in the alleged or suspected abuse, neglect or exploitation]: [E5]" -"Name if witnesses [the alleged or suspected abuse, neglect or exploitation]: [E6]" -"Action taken by the facility [in the alleged or suspected abuse, neglect or exploitation]: Called 911, EMS, DCS, Guardians, DHS, Follow-Up PCP Appt. Follow-up appt made for psych. Crisis team also arrived and spoke to client." -"Action taken by the facility [to prevent reoccurrence of such event]: Immediately termination, providing staff additional trainings." 2. A review of facility documentation revealed a written account of the incident. The document stated, "At approximately 3:25 p.m., the client was in the office and directed inappropriate language toward the staff, calling them derogatory names. In response, staff made inappropriate remarks toward the client. The client became upset and told staff to stop making comments about [R1's] mother or [R1] would become physical. Staff then challenged the client, at which point the client lunged towards staff and struck [E5] in the head. Staff raised [their], slapped the client and began punching [R1] with a closed fist. The client asked the staff to stop and get away. Staff eventually stopped; however, the client continued using profanity, kicked the staff, and pulled [E5's] hair. Staff then became more aggressive by grabbing and hitting the client again. Once the altercation ended, the house manager instructed staff to leave the office. Staff walked out, then returned briefly to gather [their] belongings. The client told staff [E5] would be reported for abuse, to which staff replied inappropriately. The house manager again directed staff to leave, and staff complied. The group home manager notified [E1] of the incident, and [E1] made the necessary calls. The group home manager assessed the client's injuries. Police and the fire department were also notified and arrived to assess the client. During the altercation, the group home manager attempted to intervene but was unable to de-escalate due to the continuous back-and-forth between staff and client." 3. While the Compliance Officer was on-site, E1 emailed E6 a termination letter. 4. A review of facility documentation revealed a "Policies and Procedures Manual." The "Respond to Out of Control Behavior, Threats/Duty Warn/Emergency Safety Response" policy stated, "A resident in the midst of a mental health crisis cannot always communicate their thoughts, feelings, or emotions clearly. They may find it difficult to understand what others are saying. It is important to emphasize with the person's feelings, stay calm, and try to de-escalate the crisis... 4) Avoid overreacting. Keep your voice calm, relax, and use a warm, friendly and slow demeanor; do not make sudden movement; do not touch the resident unless invited to do so; do not overreact; do not criticize.... 8) Avoid arguing, coercing, insisting, or reasoning with the resident. Do not challenge them. Explaining your actions may reassure someone who's having irrational thoughts. Express support and concern. Ask how you can help." 5. The Compliance Officer observed video footage of the incident. In the video, E5 and E6 are in the privacy room (15:13:54-15:14:36). R1 is not in the room and was heard yelling; however, R1's statements are incomprehensible. R1 came to the privacy room door, and words were exchanged between E5 and R1 (15:14:37). R1 enters the room and pushes E5 (15:15:44). E5 pushes R1, grabs and holds their arm, and slaps them twice (15:14:45 to 15:14:48). E5 puts R1 on the ground by holding one of their arms and their head, and then was crouched over them (15:14:49-15:16:00). E5 rolls R1 over and keeps their hand on R1 (15:16:01-15:16:11). E5 lifts R1's back off the ground using both hands (15:16:18). E5 slaps R1 eight times and kicks them once (15:16:39-15:16:45). E5 exits the room at 15:19:50 while E6 remains in the room with R1. 6. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. 7. A review of "PHOENIX POLICE DEPARTMENT (0723) Case Report" dated September 30, 2025, revealed "Charging Summary. This case is being submitted to the Maricopa County Attorney's Office for one count of child abuse, a violation of A.R.S. 13-13623B1, a class four felony. Count One: On 9-22-25, SPI [E5] committed child abuse by slapping the face area and kicking the upper back/head area of V1 [R1] at, [licensed facility], located in Maricopa County."

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's compliance with the requirements in A.R.S. § 8-804(C), for one of six personnel records sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: A.R.S. 8-804(C). "C. Licensees that do not contract with the state and that employ persons who provide direct services to children pursuant to title 36, chapter 7.1 must submit to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct central registry background checks. The department of health services shall verify whether licensees, pursuant to title 36, chapter 7.1, have complied with the requirements of this subsection and any rules adopted by the department of health services to implement this subsection." 1. A review of E6's (hired as a group home manager and behavioral health technician) personnel record revealed no documentation of a Department of Child Safety (DCS) central registry check being completed. 2. In an interview, E1 reported there was no DCS central registry check completed for E6. 3. A review of the daily staff schedule revealed E6 worked on September 22, 2025, which was E6's first day of employment. 4. While the Compliance Officer was on-site, E1 emailed E6 a termination letter. 5. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure that a resident was treated with dignity, respect, and consideration, for one of one records sampled. The deficient practice posed a risk as E5 exhibited inappropriate behavior toward R1.

findings: 1. A review of facility documentation revealed a "Report of Unusual Occurrence" for R1 dated in 2025 at 03:25 PM. The report detailed a verbal and physical altercation between R1 and E5 (hired as a behavioral health technician), with E6 (hired as a group home manager and behavioral health technician) as a witness. The report stated, -"The nature and extent of the adult's vulnerability [in the alleged or suspected abuse, neglect or exploitation]: Suspected child abuse, consisting of staff slapped, kicked and punched client." -"The nature and extent of the adult's child injuries or physical neglect or of the exploitation of the adult's child property [include changes to the resident's physical, cognitive, functional, or emotional condition]: Client has scratches on arms and a welt mark across [R1]'s face. Client was crying, client stated [R1] was okay after [R1] was asked multiple times. EMS also checked [R1] and checked vitals and stated everything is normal." -"Name of individuals involved [in the alleged or suspected abuse, neglect or exploitation]: [E5]" -"Name if witnesses [the alleged or suspected abuse, neglect or exploitation]: [E6]" -"Action taken by the facility [in the alleged or suspected abuse, neglect or exploitation]: Called 911, EMS, DCS, Guardians, DHS, Follow-Up PCP Appt. Follow-up appt made for psych. Crisis team also arrived and spoke to client." -"Action taken by the facility [to prevent reoccurrence of such event]: Immediately termination, providing staff additional trainings" 2. A review of facility documentation revealed a written account of the incident. The document stated, "At approximately 3:25 p.m., the client was in the office and directed inappropriate language toward the staff, calling them derogatory names. In response, staff made inappropriate remarks toward the client. The client became upset and told staff to stop making comments about [R1's] mother or [R1] would become physical. Staff then challenged the client, at which point the client lunged towards staff and struck [E5] in the head. Staff raised [their], slapped the client and began punching [R1] with a closed fist. The client asked the staff to stop and get away. Staff eventually stopped; however, the client continued using profanity, kicked the staff, and pulled [E5's] hair. Staff then became more aggressive by grabbing and hitting the client again. Once the altercation ended, the house manager instructed staff to leave the office. Staff walked out, then returned briefly to gather [their] belongings. The client told staff [E5] would be reported for abuse, to which staff replied inappropriately. The house manager again directed staff to leave, and staff complied. The group home manager notified [E1] of the incident, and [E1] made the necessary calls. The group home manager assessed the client's injuries. Police and the fire department were also notified and arrived to assess the client. During the altercation, the group home manager attempted to intervene but was unable to de-escalate due to the continuous back-and-forth between staff and client." 3. While the Compliance Officer was on-site, E1 emailed E6 a termination letter. 4. A review of facility documentation revealed a "Policies and Procedures Manual." The "Respond to Out of Control Behavior, Threats/Duty Warn/Emergency Safety Response" policy stated, "A resident in the midst of a mental health crisis cannot always communicate their thoughts, feelings, or emotions clearly. They may find it difficult to understand what others are saying. It is important to emphasize with the person's feelings, stay calm, and try to de-escalate the crisis... 4). Avoid overreacting. Keep your voice calm, relax, and use a warm, friendly and slow demeanor; do not make sudden movement; do not touch the resident unless invited to do so; do not overreact; do not criticize.... 8) Avoid arguing, coercing, insisting, or reasoning with the resident. Do not challenge them. Explaining your actions may reassure someone who's having irrational thoughts. Express support and concern. Ask how you can help." 5. The Compliance Officer observed video footage of the incident. In the video, E5 and E6 are in the privacy room (15:13:54-15:14:36). R1 is not in the room and was heard yelling; however, R1's statements are incomprehensible. R1 came to the privacy room door, and words were exchanged between E5 and R1 (15:14:37). R1 enters the room and pushes E5 (15:15:44). E5 pushes R1, grabs and holds their arm, slaps them twice (15:14:45 to 15:14:48). E5 puts R1 on the ground by holding one of their arms and their head, and then was crouched over them (15:14:49-15:16:00). E5 rolls R1 over and keeps their hand on R1 (15:16:01-15:16:11). E5 lifts R1's back off the ground using both hands (15:16:18). E5 slaps R1 eight times and kicks them once (15:16:39-15:16:45). E5 exits the room at 15:19:50 while E6 remains in the room with R1. 6. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings. 7. A review of "PHOENIX POLICE DEPARTMENT (0723) Case Report" dated September 30, 2025 revealed "Charging Summary This case is being submitted to the Maricopa County Attorney's Office for one count of child abuse, a violation of A.R.S. 13-13623B1, a class four felony. Count One: On 9-22-25, SPI [E5] committed child abuse by slapping the face area and kicking the upper back/head area of V1 [R1] at, [licensed facility], located in Maricopa County."

rule: R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure that a resident was not subjected to restraint, for one of one records sampled. The deficient practice posed a risk as a resident was restrained.

findings: R9-10-101(201): "Restraint” means any physical or chemical method of restricting a patient’s freedom of movement, physical activity, or access to the patient’s own body. 1. A review of facility documentation revealed a "Policies and Procedures Manual." The "Respond to Out of Control Behavior, Threats/Duty Warn/Emergency Safety Response" policy stated, "A resident in the midst of a mental health crisis cannot always communicate their thoughts, feelings, or emotions clearly. They may find it difficult to understand what others are saying. It is important to emphasize with the person's feelings, stay calm, and try to de-escalate the crisis... 4). Avoid overreacting. Keep your voice calm, relax, and use a warm, friendly and slow demeanor; do not make sudden movement; do not touch the resident unless invited to do so; do not overreact; do not criticize." 2. The Compliance Officer observed video footage of the incident. In the video, E5 and E6 are in the privacy room (15:13:54-15:14:36). R1 is not in the room and was heard yelling; however, R1's statements are incomprehensible. R1 came to the privacy room door, and words were exchanged between E5 and R1 (15:14:37). R1 enters the room and pushes E5 (15:15:44). E5 pushes R1, grabs and holds their arm, slaps them twice (15:14:45 to 15:14:48). E5 puts R1 on the ground by holding one of their arms and their head, and then was crouched over them (15:14:49-15:16:00). E5 rolls R1 over and keeps their hand on R1 (15:16:01-15:16:11). E5 lifts R1's back off the ground using both hands (15:16:18). E5 slaps R1 eight times and kicks them once (15:16:39-15:16:45). E5 exits the room at 15:19:50 while E6 remains in the room with R1. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-712.C.23.d.i-ii. Medical Records C. An administrator shall ensure that a resident's medical record contains: 23. Documentation of medication administered to the resident that includes: d. For a psychotropic medication, when administered initially or on a PRN basis: i. An assessment of the resident's behavior before administering the psychotropic medication, and ii. The effect of the psychotropic medication administered;

evidence: Based on record review and interview, the administrator failed to ensure that a resident's medical record contained documentation of a medication administered to the resident that included for a psychotropic medication administered on a PRN basis an assessment of the resident's behavior before administering the psychotropic medication and the effect of the psychotropic medication administered, for one of one resident record sampled. The deficient practice posed a risk as the effect of the mediation on the resident was unknown.

findings: 1. A review of R1's medical record revealed a medication administration record (MAR). The MAR revealed the medication "Hydroxyzine 25mg" was taken by R1 on September 21, 2025, and September 22, 2025. However, the MAR did not contain an assessment of the resident's behavior before administering the psychotropic medication, and the effect of the psychotropic medication administered. 2. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.


summary: Compliance (Initial) - 3/6/2025 - 3/13/2025


facility_name: ARTEMIS ADOLESCENT HEALING CENTER

summary: Complaint;Initial Monitoring - 6/26/2025

raw_content: An on-site abbreviated follow-up inspection and investigation of complaints 00134632, 00134685, and 00134802 were conducted on June 26, 2025, and the following deficiencies were cited:

rule: R9-10-703.A.2.a-b. Administration A. A governing authority shall: 2. Establish, in writing: a. A behavioral health residential facility's scope of services, and b. Qualifications for an administrator;

evidence: Based on documentation review and interview, the governing authority failed to establish in writing the behavioral health residential facility's scope of services. The deficient practice posed a risk as the scope of services did not include the correct age group.

findings: 1. A review of Department documentation revealed a Behavioral Health Residential Facility License (BH10722) was issued on April 29, 2025. 2. A review of facility documentation revealed a policy titled "RES 00001 - Residential Services" (dated on March 1, 2025). The procedure stated "Catalina Behavioral Health... Description of the Residential Program... Artemis Healing Center is a substance abuse treatment residential treatment center... Services are provided to adults eighteen years of age and up." 3. A review of R2's, R3's, and R4's medical records revealed each resident was under eighteen (18) years of age. 4. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.

rule: R9-10-707.A.6. Admission; Assessment 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 documentation review, record review, and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination (H&P) or a registered nurse (RN) 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 five resident records 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 facility documentation revealed a policy titled "Clin 00004 - Assessment" (dated on March 1, 2025). The procedure stated "A medical history and physical or nursing assessment will be conducted, that will include... 3. A medical history and physical or nursing assessment will be conducted within 30 calendar days before admission, or within 72 hours after admission. 4. The medical history and physical or nursing assessment will be documented in the resident’s medical record within 72 hours after admission." 2. A review of R2's medical record (admitted in June 2025) revealed no documentation which indicated a medical practitioner performed an H&P or an RN performed a nursing assessment. 3. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.

rule: R9-10-707.A.7. Admission; Assessment A. An administrator shall ensure that: 7. If a medical practitioner performs a medical history and physical examination or a nurse performs a nursing assessment on a resident before admission, the medical practitioner enters an interval note or the nurse enters a progress note in the resident's medical record within seven calendar days after admission;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure when a medical practitioner performed a medical history and physical examination (H&P) on a resident before admission, the medical practitioner entered an interval note in the resident's medical record within seven calendar days after admission, for three of five resident records sampled. The deficient practice posed a risk of not meeting a resident's needs if no medical history and physical examination was completed to assess a resident's needs prior to treatment.

findings: 1. A review of facility documentation revealed a policy titled "Clin 00004 - Assessment" (dated on March 1, 2025). The procedure stated "A medical history and physical or nursing assessment will be conducted, that will include... 3. A medical history and physical or nursing assessment will be conducted within 30 calendar days before admission, or within 72 hours after admission. 4. The medical history and physical or nursing assessment will be documented in the resident’s medical record within 72 hours after admission." 2. A review of R3's medical record (admitted in June 2025) revealed an H&P performed in May 2025; however, there was no evidence of a documented progress note from a medical practitioner within seven (7) calendar days after admission. 3. A review of R4's medical record (admitted in June 2025) revealed an H&P performed in May 2025; however, there was no evidence of a documented progress note from a medical practitioner within seven (7) calendar days after admission.. 4. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.

rule: R9-10-708.A.5. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 5. If the treatment plan was completed by a behavioral health technician, is reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan is complete and accurate and meets the resident's treatment needs; and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure when a treatment plan was completed by a behavioral health technician (BHT), within 24 hours a behavioral health professional (BHP) reviewed and signed the treatment plan to ensure it was complete and accurate and met the residents' treatment needs, for two of five resident records sampled. The deficient practice posed a risk as a description of the resident's behavioral health services to be provided was not reviewed within 24 hours to ensure the treatment plan was complete and accurate.

findings: 1. A review of facility documentation revealed a policy titled "Clin 00012 - Clinical Oversight" (dated on March 1, 2025). The procedure stated "Behavioral health technicians/care coordinators are trained to provide the following clinical services: Treatment planning... Behavioral health assessments... Some group counseling... If a treatment plan or behavioral health assessment is performed by a behavioral health tech/care coordinator, the BHP/supervisor that is licensed to practice independently shall review and approve the treatment plan or behavioral health assessment within 24 hours." 2. A review of R2's medical record (admitted in May 2025) revealed a treatment plan, dated in May 2025, was completed by a BHT. However, the treatment plan was not reviewed and signed by a BHP until 98 hours after. 3. A review of R3's medical record (admitted in June 2025) revealed a treatment plan, dated in June 2025, was completed by O1, a BHT. However, the treatment plan was not reviewed and signed by a BHP until 73 hours after. 4. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.

rule: R9-10-721.A.1.a. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: a. Maintained in a condition that allows the premises and equipment to be used for the original purpose of the premises and equipment;

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure the premises and equipment were maintained in a condition which allowed the premises and equipment to be used for the original purpose of the premises and equipment. The deficient practice posed a risk of the facility being able to provide a safe, functional environment, and the Department was unable to ensure the facility's compliance.

findings: 1. The Compliance Officer observed in the facility’s kitchen and living room, where large pieces of plywood had been installed to cover approximately half of the broken windows. 2. In an interview, E1 reported a resident had exhibited sudden, intense, and out-of-control behavior at the facility, which resulted in broken windows. 3. In an interview, E1 reported the replacement windows required custom fabrication by an external company, with an estimated turnaround time of five to seven weeks. E1 reported the facility had placed the order two weeks prior to June 26, 2025. 4. In an exit interview, the findings were reviewed with E1, and no further documentation or comments were provided.


summary: Compliance (Initial) - 4/23/2025


facility_name: MINGUS MOUNTAIN ESTATE RESIDENTIAL CENTER, INC

summary: Complaint - 2/25/2026

raw_content: No deficiencies were found during the on-site  investigation of complaint 00159953 conducted on February 25, 2026.


summary: Complaint;Compliance (Annual) - 6/17/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00133026 and 00133039 conducted on June 17, 2025:

inspection_type: Complaint;Compliance (Annual)

rule: R9-10-706.B.1.b.i. Personnel B. An administrator shall ensure that: 1. The qualifications, skills, and knowledge required for each type of personnel member: b. Include: i. The specific skills and knowledge necessary for the personnel member to provide the expected behavioral health services or physical health services listed in the established job description,

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a personnel member had skills and knowledge necessary for the personnel member to provide the expected behavioral health services listed in the established job description. The deficient practice posed a risk as E3 provided R1 and R2 with alcohol.

findings: 1. A review of E3's (date of hire in December 2023) personnel records revealed a job description that listed E3 as a "Client Care Technician." The job description stated "13. Exemplifies appropriate role model through physical appearance, social skills, professional words and acts, sets clear professional boundaries." 2. A review of documentation revealed a policy and procedure (dated on May 5, 2023) titled "Employee Orientation and Training." The policy stated "Final competency determinations will be made by the staff member's supervisor or Director through supervision/ observation of the employee and his/her work. These competency determinations shall include things such as: preventing of violent behaviors or behaviors harmful to the client or others. Behavior management skills and activity supervision, Symptomatology of clients' disorders and addictions." 3. A review of E3's record revealed a document titled "Orientation Checklist" dated January 15, 2025. The "Orientation Checklist" revealed E3 completed "Therapeutic Boundaries & Professional Relationships" Training on day five. However, there was no specified date for completing the training. 4. A review of E3's record revealed a document titled "Relias-Mingus Mountain Academy." The document listed E3 as having completed training on Therapeutic Boundaries and Zero Tolerance on December 27, 2024. 5. A review of the Prescott Police report stated, "[R1] said the purpose of their outing was to celebrate [R2's] discharge from Carrington House, where [R1] had been staying due to issues related to drugs. While at Buffalo Wild Wings, [E3] ordered an alcoholic drink, showing [E3's] ID to the staff. [R1] noted that the drink had tajin on the rim. It should be noted that this is consistent with the drink shown on the receipt. [R1] confirmed that they went into the bathroom to drink the alcohol. Initially, [R1] did not intend to drink, but after some peer pressure from [R2] and [E3], [R1] took a sip. [R1] also said that [E3] brought a vape pen into the bathroom (which was visible in some of the surveillance video) and [R1] and [R2] were smoking it. [R1] said that [E3] encouraged them to smoke the vape because it wouldn't show up on a drug test." 6. A review of the police report stated, "...[E3] can be seen showing the waitress [E3's] ID, and then the margarita on the receipt was delivered shortly after. The three... could clearly be seen later going to the bathroom together with the drink at timestamp 20:39:21. They then came back to the table at timestamp 20:45:20 without the glass, sat back down, and left after paying the bill." 7. In an exit interview, the findings were discussed with E1 and E4, and no additional comments or documentation were provided.

evidence: Based on record review and interview, the administrator failed to ensure a resident did not use or have access to any materials or participate in any activity that presented a threat to the resident’s health or safety based on the resident’s documented diagnosis, treatment needs, or personal history, for two of two resident sampled. The deficient practice posed a risk as E3 provided R1 and R2 with alcohol.

findings: 1. A review of R1’s (admitted in May 2025 and discharged in June 2025) record revealed an incident report dated in June 2025. R1’s incident report stated “...made an allegation regarding [R2], [R1], and a staff [E3]. R1 was questioned. Information from allegation was reported to Prescott Valley PD, DCS Hotline, and MMYTC QA for investigation.” 2. A review of R1’s (admitted in May 2025 and discharged in June 2025) record revealed a treatment plan (dated in June 2025). The treatment plan stated, "Symptoms/issues needing to be addressed: ...Substance use..." 3. A review of R2’s (admitted in January 2025 and discharged in June 2025) record revealed a treatment plan (dated in April 2025). The treatment plan stated, "Symptoms/issues needing to be addressed: [Substance] use... risky behaviors..." According to R2's treatment plan, R2 was diagnosed with Opioid-induced mood disorder, PTSD, Methamphetamine use disorder and fentanyl use disorder. 4. A review of the police report stated, "...[E3] can be seen showing the waitress [E3's] ID, and then the margarita on the receipt was delivered shortly after. The three... could clearly be seen later going to the bathroom together with the drink at timestamp 20:39:21. They then came back to the table at timestamp 20:45:20 without the glass, sat back down, and left after paying the bill." 5. In an interview, E1 reported E3 was immediately placed on leave following the allegations and was terminated once the allegations were investigated and confirmed to be true by the Prescott Police Department. 6. In an interview, E1 and E4 acknowledged R1 and R2 had access to materials and participated in activities that presented a threat to the resident’s health and safety based on the resident’s documented diagnosis, treatment needs, or personal history. 7. In an exit interview, the findings were discussed with E1 and E4, and E4 confirmed E3 was terminated and will no longer be working for the facility.


summary: Complaint - 5/12/2025

raw_content: An on-site complaint investigation of complaint 00130160 was conducted on May 12, 2025 and the following deficiencies were cited:

rule: R9-10-708.A.4.c. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: c. The signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed to include the signature of the resident’s representative, and date signed, or documentation of the refusal to sign, for two of two current residents sampled, and one of one discharged resident sampled. The deficient practice posed a risk if the resident's representatives were not required to sign.

findings: R9-10-101(165) "Patient’s representative” means: a. A patient’s legal guardian; b. If a patient is less than 18 years of age and not an emancipated minor, the patient’s parent; c. If a patient is 18 years of age or older or an emancipated minor, an individual acting on behalf of the patient with the written consent of the patient or patient’s legal guardian; or d. A surrogate as defined in A.R.S. § 36-3201." R9-10-101(196) "Resident’s representative” means the same as “patient’s representative” for a resident. ARS 1-602(A) All parental rights are exclusively reserved to a parent of a minor child without obstruction or interference from this state, any political subdivision of this state, any other governmental entity or any other institution, including: 5. The right to make all health care decisions for the minor child, including rights pursuant to sections 15-873, 36-2271 and 36-2272, unless otherwise prohibited by law. H. For the purposes of this section, "parent" means the natural or adoptive parent or legal guardian of a minor child. 1. A review of Department documentation revealed the facility was authorized to provide services to individuals under the age of 18. 2. A review of R1’s (admitted in August 2024 and discharged in February 2025) medical record revealed documentation of R1's legal guardian and R1's treatment plan, dated in February 2025. R1 signed R1’s treatment plan, however R1’s treatment plan did not include R1’s representative’s signature, and date signed, or documentation of the refusal to sign. 3. A review of R2’s (admitted in December 2024) medical record revealed documentation of R2's legal guardian, and R2's treatment plan, dated in December 2024. R2 signed R2’s treatment plan, however, R2’s treatment plan did not include R2’s representative’s signature, and date signed, or documentation of the refusal to sign. 4. A review of R3’s (admitted in May 2024) medical record revealed documentation of R3's legal guardian, and R3's treatment plan, dated in February 2025. R3 signed R3’s treatment plan, however, R3’s treatment plan did not include R3’s representative’s signature, and date signed, or documentation of the refusal to sign. 5. In an interview, E1 reported residents were required to sign their treatment plan per The Joint Commission requirements, as the facility was accredited by The Joint Commission. E1 acknowledged the facility was licensed by the Department and not The Joint Commission. E1 reported the facility was in compliance as the regulation stated “resident or resident’s representative.” E1 acknowledged residents at the behavioral health residential facility were under the age of eighteen. E1 acknowledged the rule requirements and definitions however E1 stated the facility was in compliance. E1 reported resident representatives signed the treatment for consents, which included the treatment plans. 6. In an exit interview, the findings were discussed with E2 and no additional statements or documentation were provided.

evidence: Based on record review and interview, the administrator failed to ensure a resident did not use or have access to any materials or participate in any activity that presented a threat to the resident’s health or safety based on the resident’s documented diagnosis, treatment needs, or personal history, for one of one discharged resident sampled. The deficient practice posed a risk as R1 was able to pierce R1’s lip and nose with sharp materials.

findings: 1. A review of R1’s (admitted in August 2024 and discharged in February 2025) revealed an incident report dated in February 2025. R1’s incident report stated “Diagnoses…Self-harming behavior – Diagnosed On 8/6/24…Suicide ideation – Diagnosed On 8/6/24…Incident Details on 2/18, a contraband check was completed in the house by staff members. A razor, a large needle tool from a clay set, an alcohol wipe, and several metal piercings were found in the room. Upon questioning, [R1] admitted to all the contraband items being [R1’s] and also disclosed that [R1] utilized the items found to pierce [R1’s] left nostril and inner lip area. [R1] was brought to nursing for an assessment and case manager and therapist were notified of the incidents. All contraband was removed from client’s room and locked up/disposed of appropriately.” 2. In an interview, E1 reported personnel members were unaware of how R1 brought the contraband into the facility. E1 reported residents attend the Mingus Mountain school and are accompanied by Mingus Mountain personnel members throughout the day. E1 acknowledged R1 had access to materials which posed a threat to R1’s safety and R1 was able to use those materials to pierce R1’s lip and nose. E1 reported school was not considered an outing and residents were only searched when returning from school if there was a reason to suspect contraband. 3. In an interview, E2 reported E2 received a report about a resident's visitor bringing in contraband but was unable to confirm or verify if R1 was the resident noted in the report. 4. In an exit interview, the findings were discussed with E2 and no additional statements or documentation were provided.


summary: Complaint - 12/10/2024

raw_content: An on-site investigation of complaint AZ00220066 was conducted on December 10, 2024 and the following deficiencies were cited :

rule: A.R.S. § 36-424. Inspections; suspension or revocation of license; report to board of examiners of nursing care institution administrators and assisted living facility managers C. On a determination by the director that there is reasonable cause to believe a health care institution is not adhering to the licensing requirements of this chapter, the director and any duly designated employee or agent of the director, including county health representatives and county or municipal fire inspectors, consistent with standard medical practices, may enter on and into the premises of any health care institution that is licensed or required to be licensed pursuant to this chapter at any reasonable time for the purpose of determining the state of compliance with this chapter, the rules adopted pursuant to this chapter and local fire ordinances or rules. Any application for licensure under this chapter constitutes permission for and complete acquiescence in any entry or inspection of the premises during the pendency of the application and, if licensed, during the term of the license. If an inspection reveals that the health care institution is not adhering to the licensing requirements established pursuant to this chapter, the director may take action authorized by this chapter. Any health care institution, including an accredited hospital, whose license has been suspended or revoked in accordance with this section is subject to inspection on application for relicensure or reinstatement of license.

evidence: Based on documentation review, observation, and interview, the licensee failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license. The deficient practice posed a risk as such action shall be deemed reasonable cause to believe a substantial violation exists.

findings: A.R.S. \'a7 36-427(B) If the licensee, the chief administrative officer or any other person in charge of the institution refuses to permit the department or its employees or agents the right to inspect the institution's premises as provided in section 36-424, such action shall be deemed reasonable cause to believe that a substantial violation under subsection A, paragraph 3 of this section exists. 1. A review of the Department documentation revealed the facility's perpetual license was effective on June 15, 2000. 2. The Compliance Officer arrived at the facility at 10:23 AM to conduct a complaint inspection. Upon arrival, the Compliance Officer contacted E1 who reported E1 would arrive at the facility in "about 20 minutes." The Compliance Officer explained to E1 that the Compliance Officer would begin the inspection with the staff on-site while waiting for E1. 3. The Compliance Officer knocked on the facility's door at 10:25 AM. The door was answered by E2. The Compliance Officer identfied themself with ID. E2 reported E2 did not know who the Compliance Officer was and would not let the Compliance Officer on site. The Compliance Officer explained the role of licensing and that licensed health care institutions are required to grant access to state Compliance Officers. E2 reported a second time to the Compliance officer would not be granted access to the facility. E2 then went inside to call E2's boss. 4. In an interview, E2 came back to the facility's front door and reported E2 spoke to E2's boss and still would not let the Compliance Officer onto the premises. E2 reported E2 did not know who E1 is. E2 refused to give the Compliance Officer E2's name and reported E2 did not know E2's title. E2 reported E2 "was looking after the girls" and the "girls were in quarantine." E2 then stated, "you are starting to piss me off" and told the Compliance Officer to go wait in the car until E1 arrived. The Compliance Officer went to the car and called a Health Care Compliance Manager at 10:35 AM. 5. The Compliance Officer observed E1 arrived at the facility at 10:47 AM. E1 granted the Compliance Officer access to the facility. The Compliance Officer observed E1 explained to E2 that the facility is required to grant access to state licensing at all times. E2 acknowledged to E1 that E2 did not grant the Compliance Officer access and reported E2 now understood the requirement. 6. In an interview, E2 apologized to the Compliance Officer for not granting the Compliance Officer access. E2 acknowledged complete acquiescence in entry was not granted. 7. In an interview, E1 acknowledged the licensee failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license. E1 reported E2 is a new employee and will undergo "retraining" after this incident.

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

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a personnel record was maintained to include documentation of compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-425.03, for one of two personnel members sampled. The deficient practice posed a risk if E2 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 arrived on site at 10:25 AM. The Compliance Officer observed E2 was the only personnel member on-site. E2 reported residents were in "quarantine" and E2 would not allow the Compliance Officer to enter the premises. 2. A review of E2's personnel record revealed E2 was hired as a "Client Care Technician" (BHPP). E2's personnel record revealed no valid fingerprint clearance card was available for review. 3. A review of the Arizona Department of Public Safety (AZDPS) Fingerprint Clearance Status website revealed E2's fingerprint clearance card expired on March 17, 2021. The AZDPS website also revealed an application was received for a new fingerprint clearance card on December 3, 2024, and the application was "In Process." However, the application was not within seven working days after E2 began employment at the facility. 4. A review of facility documentation revealed facility staffing schedules which indicated E2 worked alone with residents from 3:00 PM to 11:00 PM on December 1-3 and 8-9, 2024. The schedule also indicated E2 was scheduled to work alone with residents from 3:00 PM to 11:00 PM on December 10, 15-17, and 22-24, 2024. 5. In an interview, E1 acknowledged documentation of compliance with A.R.S. \'a7 36-425.03(A) was not available for review in E2's personnel record.

rule: B. An administrator shall ensure that: 1. A behavioral health residential facility has a: a. Room that provides privacy for a resident to receive treatment or visitors; and

evidence: Based on observation and interview, the administrator failed to ensure the behavioral health facility had a room to provide privacy for a resident to receive treatment or visitors. The deficient practice posed a risk if the administrator was unable to ensure confidentiality in treatment as well as a resident's right to privacy in treatment and visitation.

findings: R9-10-722.B.8.a. An administrator shall ensure that a resident bedroom complies with the following: Is not used as a common area. R9-10-101.52.a. "Common area" means licensed space in a health care institution that is: Not a resident's bedroom or a residential unit. R9-10-101.203. "Room" means space contained by a floor, a ceiling, and walls extending from the floor to the ceiling that has at least one door. 1. The Compliance Officer observed the facility did not have a room to provide privacy for a resident to receive treatment or visitors. 2. In an interview, the Compliance Officer requested to use the facility's privacy room to interview residents. E1 reported the facility did not have a privacy room. 3. In an interview, E1 acknowledged the facility did not have a room to provide privacy for a resident to receive treatment or visitors. E1 reported the facility may decrease residency to turn a facility bedroom into a privacy room.


summary: Compliance (Annual) - 10/24/2024

raw_content: Based on Arizona Revised Statutes \'a7 36-424(B) and Arizona Administrative Code R9-10-109(E), the Department may accept an accreditation report in lieu of an onsite compliance inspection during the time of the accreditation report. The director may not accept an accrediation report in lieu of a compliance inspection of a health care institution if the health care institution has been subject to an enforcement action pursuant to section 36-427 or 36-431.01 within the year preceding the annual licensing fee anniversary date. The licensee submitted to the Department the current accreditation report from The Joint Commission valid from January 6, 2022 through January 6, 2025. If the health care institution's accreditation report is not valid for the entire licensure period, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.


summary: Complaint - 7/8/2024

raw_content: An on-site investigation of complaint AZ00212597 was conducted on July 8, 2024 and the following deficiency was cited:

rule: A. An administrator shall ensure that: 1. The requirements in subsection (B) and the resident rights in subsection (E) are conspicuously posted on the premises;

evidence: Based on observation and interview, the administrator failed to ensure the resident rights in subsection (E) were conspicuously posted on the premises. The deficient practice posed a risk if residents were not aware of all relevant resident rights while resident at BH1122.

findings: 1. The Compliance Officer observed a facility posting titled "Patient Rights" on the premises. The posting stated, "Youth Receiving Services at Mingus Mountain Youth Treatment Center have the Following Rights: (Per A.A.C. R9-10-311)..." The posting listed requirements in subsection (B) and the patient rights in subsection (D) from Article 3 - Behavioral Health Inpatient Facilities. The resident rights in subsection D of A.A.C. R9-10-311 did not include all of the resident rights in subsection E of A.A.C. R9-10-711. 2. In an interview, E1 acknowledged the posted resident rights were not the resident rights required by R9-10-711(A)(1).


summary: Complaint - 3/19/2024

raw_content: An on-site investigation of complaint was conducted on March 19, 2024 and the following deficiencies were cited :

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

evidence: Based on record review, documentation review, and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after a resident inflicted self-injury or had an accident that required immediate intervention by an emergency medical services provider. This deficient practice posed a health and safety risk to residents.

findings: 1. A review of R1's medical record revealed an incident report dated March 13, 2024. The report stated, "...Clients then got in the van with [R1] driving and began driving down the driveway. The van got going to (sic) fast and clients rolled the van down the driveway taking out the fence and the neighbors fence. Clients then got out the (sic) van and began Awoling. [R1] ran to Prescott country club where [R1] eventually asked for help because [R1] was injured from the accident. A man helped them and had them call mingus and then called the police and stayed with them until police arrive as well as EMT's to the scene ...Clients were separated by police and taken to the hospital for further evaluation." 2. A review of R2's medical record revealed an incident report dated March 13, 2024. The report stated, "...Clients then got in the van with [R1] driving and began driving down the driveway. The van got going to (sic) fast and clients rolled the van down the driveway taking out the fence and the neighbors fence. Clients then got out the (sic) van and began Awoling. [R2] ran to Prescott country club where [R2] asked a man for assistance as [R2] and [R1] were injured ...Clients went to hospital to be assessed and then were detained." 3. A review of facility documentation revealed an "Incident, Accident or Death Report" was created on March 14, 2024, and submitted to "T/RHBA" on March 14, 2024 at 12:59:57 AM. The document identified R1 as the "Member" and detailed the aforementioned incident. However, no documentation which showed the report was submitted to the Department within two working days of the incident was available for review. 4. A review of Department documentation revealed written notification of the aforementioned incident was not received by the Department. 5. In an interview, E1 acknowledged the administrator failed to provide written notification to the Department, within two working days after a resident inflicted self-injury or had an accident that required immediate intervention by an emergency medical services provider. E1 reported E1 would update the facility's incident reporting policies and procedures to ensure future compliance.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure, if a behavioral health residential facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a health and safety risk to residents who required continuous protective oversight due to being minors under the age of 18.

findings: 1. A review of Department documentation revealed the facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently. 2. A review of facility policies and procedures revealed a policy titled, "Program Description" which stated, "MINGUS MOUNTAIN YTC serves females ages 12 to 17 with emotional disorders, behavioral disorders, victims of physical, sexual, or emotional abuse, or substance abuse problems." 3. A review of facility policies and procedures revealed a policy titled , "Client Supervision, Policy Number GLV301" which stated, "All Mingus Mountain Youth Treatment Center employees will maintain appropriate supervision in the following critical areas ...D - Distance: All employees will have appropriate distance between themselves and the student(s) they are in direct supervision of. This is to ensure that the employee has the ability to appropriately supervise conversations and intervene for safety and well-being of our clients. E - Eyesight: Appropriate supervision involves on duty staff members performing consistent and regular unobstructed visual inspections with a clear line of sight on all clients in their care. The only exception would be when we are to provide privacy to a student such as being in the bathroom or shower. When clients are in their bedrooms for more than 15 minutes, staff members will refer to the overnight room checks standard operating procedure. A - Awareness: All employees are to have an active awareness of the clients(s) they are in direct supervision of ..." 4. A review of facility documentation revealed a document titled, "Farrington House CIR." The document detailed a "Critical Incident Review of 3/13/24 incident where three clients of Farrington House group home stole and rolled the company van, went AWOL, and were subsequently arrested." The investigation contained a section titled "Audit Findings" which stated, "Estimated Risk Level: Severe; Summary of Contributing Factors: Supervision Protocols, Staff Placement ...Supervision Protocols: The staff member on shift, based on video footage obtained, opened the locker for the clients per their request to obtain scissors to open a food package. While the staff member remained next to the locker, [R2] was not actively supervising the clients accessing the locker, as [R2] was distracted by another client. This was a violation of policy ...Staff Placement: The staff member on shift was not placed in an area where [R2] could supervise client movement throughout the home. The three clients involved in the incident were able to freely move between their bedrooms and the living room without staff intervening or resetting movement and their own position to supervise the group. This was a violation of policy. Client Supervision, GLV301 ...Staff member on shift will receive a written coaching for the two aforementioned policy violations." 5. A review of R1's medical record revealed an incident report dated March 13, 2024. The report stated, "[R1] woke up and began going to peers asking them to AWOL with her. [R1] asked clients [R2] and [R4] to join and began discussing it in [R1's] bedroom ...Client and peers were then addressed for having an unspotted conversation and talking in a room they weren't supposed to be in ...Clients began packing things and taking them to room 1 where they tore off the sensor for the windsow to the room. Clients involved then asked staff to open up the staff cabinet to grab something out of it. [R1] and a peer also caused a distraction at this time so staff would turn away from the cabinet and one of them could steal the van keys. Clients then tried to play hide and seek to create a distraction. Clients had high movement and used this as a distraction to open the window in room one where they had taken the sensor off the wall and jumped out as well as ran out the back door. Clients then got in the van with [R1] driving and began driving down the driveway ..." 6. A review of R2's and R3's medical records revealed separate incident reports dated March 13. Both incident reports indicated staff was distracted while residents planned to leave the facility, stole keys to the facility's van, and "opened the window in room one where they had taken the sensor off the wall and jumped out as well as ran out the back door." R1's, R2's, and R3's incident reports also contained a "Debriefing" section which stated, "Identified intervention opportunities that may have prevented the incident: Staff could have better supervision and slowed movement." 7. In an interview, E1 reported the facility had investigated the incident and addressed the causes identified in the investigation. E1 acknowledged the residents were minors under the age of 18 who required continuous protective oversight. E1 further acknowledged the administrator failed to ensure R1, R2, and R3 received continuous protective oversight from facility staff during the March 13, 2024 incident.


summary: Compliance (Annual) - 10/18/2023

raw_content: Based on Arizona Revised Statutes, \'a736-424(B) and Arizona Administrative Code, R9-10-109(E), the Department may not conduct an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from The Joint Commission valid from January 6, 2022 through January 6, 2025. If the health care institution's accreditation report is not valid for the entire licensure period, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.


facility_name: Montare Behavioral Health

summary: Modification - 1/28/2026

raw_content: Based on an onsite survey on January 27, 2026, the facility is approved to operate as an Inpatient Behavioral Health Facility with 15 beds.

inspection_type: Modification


summary: Complaint - 1/27/2026

raw_content:
The following deficiencies were cited at the time of the unannounced, on-site State Complaint Investigation conducted January 27, 2026, pursuant to the rules found in 9 A.C.C. 10, Article 3: Behavioral Health Inpatient Facilities for the following intakes:

00153443
00156606

Healthcare Compliance Officer
Senior Healthcare Compliance Officer
Healthcare Compliance Manager

rule: R9-10-313.C.1 Transportation; Patient Outings C. An administrator shall ensure that: 1. At least two personnel members are present on an outing;

evidence: Based on review of facility documents, patient medical record and interview, the administrator failed to ensure at least two personnel members are present on an outing. This leads to the inability to properly have supervision of patients in the facilities care while outside the facility.

findings: Facility outings documents dated December 12, 2025, revealed, the outing had one staff member present and three patients. Facility outing documents dated December 13, 2025, revealed the outing had one staff member present and four patients. Medical record for Patient #6 revealed that they reported being sexually accosted by a person on the outing and staff did not witness it. There was a one staff member on the outing. Interview with Employee #1 on January 27, 2026, confirmed, the facility does not send at least two staff members on outings.

rule: R9-10-313.C.3 Transportation; Patient Outings C. An administrator shall ensure that: 3. Each personnel member on the outing has documentation of current training in cardiopulmonary resuscitation according to R9-10-303(C)(1)(e) and first aid training;

evidence: Based on review of facility documents, personnel record, patient records and interview, the Administrator failed to ensure personnel members on outings had current CPR and first aid training. This deficient practice can lead to patient death or harm in an emergency.

findings: Facility documents for outings dated December 12, 2025, revealed Employee #4 on an outing with patients. Employee #4 was the only employee present on the outing. Evidence of Employee #4's current CPR and First Aid training were requested. None were provided. Interview with Employee #1 on January 27, 2026, confirmed, that Employee #4 CPR and First Aid were expired at the time of the outing.

rule: R9-10-323.A.1.a-b Environmental Standards A. An administrator shall ensure that: 1. The premises and equipment are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and b. Free from a condition or situation that may cause a patient or other individual to suffer physical injury;

evidence: Based on review of a previous Plan of Correction, observation, and staff interview, the Department determined that the administrator failed to ensure the facility was free from a condition or situation that may cause a patient or other individual to suffer physical injury. This deficient practice resulted in multiple opportunities that could cause physical injury in areas accessible to patients and other individuals. *This is a repeat deficiency from State Complaint Investigation, Event ID #ZNIV11, conducted on August 5, 2024.

findings: Review of facility Plan of Correction from a Complaint Investigation conducted on August 5, 2024, Event ID #ZNIV11, revealed “...Monitoring…The Facility Operations Director and Program Director will complete Environment of Care (EOC) walkthroughs once per month to review the safety and security of all spaces within the facility, including client bedrooms….” Observation on tour on January 27, 2026 revealed the following opportunities that could cause physical injury in areas accessible to patients and other individuals: Patient bathrooms lacking tamper resistant screws Patient bathroom toilets with multiple tie off points Patient bathroom grab bars lacking tamper resistant screws Patient bedframes with multiple tie off points Patient bedroom outlets and light switches lacking tamper resistant screws Patient bedroom televisions not in a case with exposed cords Patient bedroom lamp with exposed cord Patient bedroom outlet coming off the wall Nurses Station bathroom that contains oxygen tanks, vitals cart, walkers, a wheelchair, and a table Picture frames hung on wall that are not flush with the wall Employee #1 confirmed in an interview conducted on January 27, 2026, that the aforementioned observations contained opportunities that could cause physical injury in areas accessible to patients and other individuals

rule: R9-10-323.A.6.a-c Environmental Standards A. An administrator shall ensure that: 6. Garbage and refuse are: a. In areas used for food storage, food preparation, or food service, stored in covered containers lined with plastic bags; b. In areas not used for food storage, food preparation, or food service, stored: i. According to the requirements in subsection (6)(a), or ii. In a paper-lined container that is cleaned and sanitized as often as necessary to ensure that the container is clean; and c. Removed from the premises at least once a week;

evidence: R9-10-323.A.6.b.ii Based on review of the facility’s Plan of Correction, observation, and staff interview, the Department determined that the facility has failed to ensure garbage or refuse that is not used for food storage, preparation, or service is lined with paper inside the container. This deficient practice could lead to an increased risk for patient injury or asphyxiation that could lead to death.

findings: Review of facility Plan of Correction from a Complaint Investigation conducted on August 5, 2024, Event ID #ZNIV11, revealed “...Monitoring…The Facility Operations Director and Program Director will complete Environment of Care (EOC) walkthroughs once per month to review the safety and security of all spaces within the facility, including client bedrooms….” Observations made during a facility tour on January 27, 2026 revealed that garbage receptacles in patient bathrooms and common areas contained plastic liners. In interviews conducted while on tour of the facility on January 27, 2026, Employee #1 confirmed that the garbage receptacles located in the patient bathrooms and common areas were lined with plastic, not paper liners.

rule: R9-10-324.B.5.h. Physical Plant Standards B. An administrator shall ensure that: 5. A patient bathroom complies with the following: h. Has tamper-resistant lighting fixtures, sprinkler heads, and electrical outlets; and

evidence: Based on review of the facility’s Plan of Correction, observation, and staff interview, the Department determined the Administrator failed to ensure patient bathrooms contained tamper-resistant lighting fixtures, light switches and electrical outlets. This deficient practice poses the potential condition in which patients could physically harm themselves, causing physical injury or death.

findings: Review of facility Plan of Correction from a Complaint Investigation conducted on August 5, 2024, Event ID #ZNIV11, revealed “...Monitoring…The Facility Operations Director and Program Director will complete Environment of Care (EOC) walkthroughs once per month to review the safety and security of all spaces within the facility, including client bedrooms….” Observations made during a facility tour on January 27, 2026 revealed that patient bathrooms contained light switches and outlet covers fastened with regular hardware, not tamper resistant screws as well as electrical outlets that were not tamper resistant throughout the facility. Additionally, observations were made of the bathroom in the nursing station that patients are unaccompanied in contained a lighting fixture that posed a ligature risk. In interviews conducted while on tour of the facility on January 27, 2026, Employee #1 confirmed that screws used on patient bathroom light switches & outlets were fastened with regular hardware, not tamper resistant screws and electrical outlets were not tamper resistant throughout the facility. Employee #1 also confirmed that the lighting fixture in the nurses station bathroom posed a ligature risk & that patients are allowed to occupy the bathroom unaccompanied.

rule: R9-10-324.B.11.a-d Physical Plant Standards B. An administrator shall ensure that: 11. For a door located in an area of the behavioral health inpatient facility that is accessible to patients: a. A door closing device, if used on a patient bedroom door, is mounted on the public side of the door; b. A door’s hinges are designed to minimize points for hanging; c. Except for a door lever handle that contains specifi- cally designed anti-ligature hardware, a door lever handle points downward when in the latched or unlatched position; and d. Hardware has tamper-resistant fasteners; and

evidence: Based on review of the facility’s Plan of Correction, observation, and staff interview, the Department determined that the facility has failed to ensure that bedroom door hardware contained door hinges that minimize points of hanging & tamper-resistant fasteners. This deficient practice of utilizing non–tamper-resistant hardware creates a potential safety hazard by increasing the risk of self-harm, tampering, or unauthorized dismantling by patients.

findings: Review of facility Plan of Correction from a Complaint Investigation conducted on August 5, 2024, Event ID #ZNIV11, revealed “...Monitoring…The Facility Operations Director and Program Director will complete Environment of Care (EOC) walkthroughs once per month to review the safety and security of all spaces within the facility, including client bedrooms….” Observations made during a facility tour on January 27, 2026 revealed that doors on patient bedrooms contained door hinges that did not minimize points of hanging, ligatures, as well as door frames on patient bedrooms that contained standard, not tamper resistant hardware screws. In interviews conducted while on tour of the facility on January 27, 2026, Employee #1 confirmed that screws used on the door frames of patient bedroom doors were standard hardware, not tamper resistant screws & that the door hinges on the patient bedroom doors posed a ligature risk.