summary: Complaint - 12/31/2024

raw_content: An on-site investigation of complaints AZ00221248 and AZ00221272 was conducted on December 31, 2024 and the following deficiencies were cited :

rule: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

evidence: Based on documentation review and interview, an administrator failed to ensure residents were treated with dignity, respect, and consideration. The deficient practice posed a risk to the physical health and safety of R2, R3, and R4.

findings: 1. A review of facility documentation revealed four incident reports from December 28, 2024. Each incident report was for a different resident - R1, R2, R3, and R4, surrounding the arrest of R1 on December 28, 2024 due to R1's conduct toward other residents. 2. A review of R1's (admitted December 2024) incident report revealed the following information: "The member that was involved was [R1]. Staff involved [E8] and [E7] and Tucson Police Department. Since [R1's] intake, [R1] has been touching [residents] and [personnel] inappropriately. [R1] has made sexual comments towards peers and would touch peers inappropriately and would ignore any cues or reminders of [facility] boundaries/expectations. On 12/27/2024, [R2] was using the bathroom. It was reported by [R2] that while [R2] was using the bathroom, [R1] opened the door and stared at [R2] while [R2] was naked, [R2] reported that [R1] needed many cues to please leave the bathroom. After several cues, [R1] complied and left the bathroom. [R2] told staff that [R1] has continuously been touching [R2] inappropriately and saying sexual comments such as 'If I make this basketball shot, I will make you suck my [body part]'. [R2] reported that [R1] has also said 'Would you like to go to pound town' and 'If you can please suck my [body part]', [R1] ignores staff cues for boundaries and the sexual comments. Around 9am on 12/28/24, [R2] wished to press charges on [R1] for sexual assault, after [R1] grabbed [R2]'s butt in passing. Tucson Police was called at 9:50a.m. and arrived at 10:15am. Police spoke with on-call supervisor and staff and other [residents] regarding [R1]'s behaviors. [R1's] guardian was spoke to directly and DCS voice message was left, On-Call and Supervisor was notified. [R1] was then arrested around 12pm by Tucson Police department and was removed off of the site, [R1] is currently in custody and will not be returning to [facility]." 3. A review of R2's (admitted December 2024) incident report revealed the following information: "The staff that was involved was [E8] and [E7] and Tucson Police Department. [R2] reported that [R1] has been touching [R2] inappropriately, sexually harassing [R2] and stating sexual comments towards[R2], [R2] reported that while [R2] was using the bathroom on 12/27/2024, [R1] stormed in and [R2] had to cue [R1] many times for [R1] to get out of the bathroom. [R2] reported that [R1] stayed in the bathroom and stared at [R2] ([R2] was naked during this time). [R1] finally complied after multiple cues [R2] reported. [R2] reported to the police officer that [R1] grabbed [R2]'s butt and during the time of [R2's] time at [the facility], [R1] has touched [R2's] leg, thigh, face and butt. [R2] reported that during a movie time [R1] would try to lay [R1's] head to [R2's] lap. [R2] would ask [R1] to please not touch [R2] and [R2] stated that [R2] would have to get up from the couch so [R1] can leave [R2] alone. [R2] reported that [R1] has stated to [R2] 'If I make this basketball shot, I will make you suck my [body part].' Tucson police was called at 9:50am and arrived at 10:15am. Police spoke with on call supervisor and staff and other [residents] regarding [R1's] behavior. [R2's] guardians were notified and decided to remove [R2] from the facilty..." 4. A review of R3's (admitted December 2024) incident report revealed the following information: "The staff that was involved was [E8] and [E7] and Tucson Police Department. [R3] reported to staff that [R1] was touching [R3] inappropriately and stating sexual comments towares [R3]. [R3] has reported to staff for the past two weeks that [R1] has been touching [R3] inappropriately (Thighs, legs, face) and [R3] would ask [R1] to please stop, [R1] did not comply. [R3] reported to staff that [R1] grabbed [R3's] face and forced a kiss on [R3's] cheek. Staff did not witness this interaction, but [R3] reported it to staff on 12/28/2024. [R3] decided to press charges on [R1] when Tucson Police Department was here for [R2] and asked to chat with [R3] if [R3] had any experience with [R1]. [R3's] guardian, on-call, and supervisor was notified." 5. A review of R4's (admitted December 2024) incident report revealed the following information: "The staff that was involved was [E8] and [E7] and Tucson Police Department. [R4] reported to staff that [R1] has been touching [R4] inappropriately and stating inappropriate comments to [R4]. While Tucson Police Department was here for [R1] due to charges being pressed by [R2], police officer asked to speak with [R4] on [R4's] own experience with [R1]. [R4] stated that member has been touching [R4] (thighs, legs, arms) and went into [R4's] bedroom while [R4] was changing. When this incident happened, [R1] laughed for walking in while [R4] was changing and needed several cues to leave [R4's] bedroom. [R4] decide that [R4] would like to press charges on [R1]. [R4's] guardian, supervisor and on-call was notified." 6. In an interview with R3 and R4, R3 and R4 reported R3 and R4 were consistenly uncomfortable around R1 due to R1's behavior towards R2, R3, and R4. R3 and R4 reported R3 and R4 notified several different staff of this several times before December 28, 2024. The staff R3 and R4 informed included E6, E7, and E8. However, E3 and E4 reported E3 and E4 were dismissed by staff each time R3 and R4 spoke to staff about issues with R1. 7. In an exit interview, E1, E2, E3, and E4 were informed of the findings. E1, E2, E3, and E4 provided no additional information.

rule: E. A resident has the following rights: 3. To receive privacy in treatment and care for personal needs, including the right not to be fingerprinted, photographed, or recorded without consent, except: c. For video recordings used for security purposes that are maintained only on a temporary basis;

evidence: Based on observation and interview, an administrator failed to ensure the behavioral health residential facility had a room providing 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 for privacy in treatment and visitation.

findings: 1. The Compliance Officer observed the facility had no privacy room for either individual nor group counseling. 2. In an interview, E1 reported the residents received individual counseling in their bedrooms. E1 reported the residents received group counseling in the living room, dining room, or kitchen. 3. The Compliance Officer observed four residents in the facility. The Compliance Officer observed each resident had their own bedroom. 4. The Compliance Officer observed security cameras in the living room, dining room, and kitchen. The security camera live footage was displayed on a television screen in an office, which was kept locked and available to facility staff. 5. In an exit interview, E1 reported there was rarely a situation in which the living room, dining room, or kitchen were not private to participants in the group counseling sessions and facility staff. However, when exiting the facility, the Compliance Officer walked through the living room and observed the residents in a group counseling session in the kitchen.


state: AZ

facility_name: INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT

summary: Complaint - 12/17/2024

raw_content: An on-site investigation of complaint AZ00220465 was conducted on December 17, 2024 and the following deficiencies were cited :

inspection_type: Complaint

rule: C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure documentation required by Article 7 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: 1. The Compliance Officer requested the following at 9:08 AM: -Resident Medical Records (complete with all required documents) for R1, R2, R3, and residents discharged within the last 12 months; -Personnel Records (complete with all required documents) for E1, E2, E3, E4, E5, and E6; -Policies and procedures; -Scope of services; -Employee disaster drills from the last 12 months; -Resident and employee evacuation drills from the last 12 months; -Current Fire Inspection Report; -Clinical Oversight for BHT's; and -Incident Reports from the last 12 months. 2. The following documentation was not provided to the Compliance Officer for review by 11:08 AM: -Resident Medical Records (complete with all required documents) for R1, R2, R3, and residents discharged within the last 12 months; -Documentation of a discharge summary for R1; -Documentation of the completed training of emergency safety responses for applicable personnel members; -Clinical Oversight for E1, E4, and E5; and -All Incident Reports from the last 12 months. 3. In an exit interview, E1, O1, O2, O3, O4, O5, and O6 reviewed the findings and no additional documentation was provided.

rule: B. An administrator shall ensure that: 2. A personnel member's skills and knowledge are verified and documented: b. According to policies and procedures; and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented according to policies and procedures, for five of six personnel records sampled. The deficient practice posed a risk as a process reinforces and clarifies standards expected of employees.

findings: 1. A review of the facility's policies and procedures revealed a policy and procedure titled, "Staff Qualifications" (revised December 2023). The policy and procedure stated, "The qualifications, skills, and knowledge required for each type of personnel member are based on... c. The qualifications, skills, and knowledge include... iii. The type and duration of education that the personnel member has or that may allow the personnel member to acquire the specific skills and knowledge needed to provide the expected services listed in the job description." 2. A review of facility documentation revealed a document titled, "[Behavioral Health Technician] Job Description[.]" The document stated, "Qualifications: Experience - One year verified experience volunteering or working with children diagnosed with Autism Spectrum Disorder (ASD) or related disabilities... Certification - Registered Behavior Technician (RBT) certification required (within 90 days from beginning the training curriculum)." 3. A review of E1's, E2's, E3's, E4's, and E5's personnel records revealed the personnel were hired as a Behavioral Health Technicians. However, documentation of RBT certification within 90 days from beginning the training curriculum for E1, E2, E3, E4, and E5 was not available for review. 4. In an exit interview, E1, O1, O2, O3, O4, O5, and O6 reviewed the findings and no additional documentation or statements were provided.

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

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a resident's behavioral health issue and treatment needs were within the behavioral health residential facility's scope of services. The deficient practice posed a health and safety risk as R1 and R2 were actively a danger to other residents.

findings: A.A.C. R9-10-101(31) "Behavioral health inpatient facility" means a health care institution that provides continuous treatment to an individual experiencing a behavioral health issue that causes the individual to: Have a limited or reduced ability to meet the individual's basic physical needs; Suffer harm that significantly impairs the individual's judgment, reason, behavior, or capacity to recognize reality; Be a danger to self; Be a danger to others; Be persistently or acutely disabled, as defined in A.R.S. \'a7 36-501; or Be gravely disabled. A.A.C. R9-10-101(36) "Behavioral health residential facility" means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: a. Limits the individual's ability to be independent, or b. Causes the individual to require treatment to maintain or enhance independence. 1. A review of the facility's policies and procedures revealed a section titled "ASSESSMENT AND INTERVENTION (AIC) BEHAVIORAL HEALTH RESIDENTIAL FACILITY PROGRAM DESCRIPTION." The program description contained a section titled AIC Scope which stated, "Assessment and Intervention (AIC) program has been established to fill the need for a Level II community-based program for the care and treatment for seriously emotionally disabled children who would otherwise be in higher levels of care. The program has a capacity to serve up to eight children, male or female, between the ages of 8-17. Referral issues are reviewed prior to a client's placement to ensure that those issues will not impact negatively on clients already placed at AIC. Staff are expected to circulate among clients so that clients are not left unattended for more than fifteen minutes during waking hours ...Admission Criteria: Appropriate candidates and circumstances are included in the Inclusionary and Exclusionary Criteria. Exclusionary Criteria:...Members with medical complexities exceeding the facility's ability to safely manage their care. Members who are exhibiting behaviors that are unable to be safely managed in the program setting..." 2. A review of R1's (admitted November 2024) medical record revealed a "Comprehensive Assessment" dated November 11, 2024, which stated, "Presenting Concerns... [R1] was reported to have the following behaviors: Verbal and physical aggression, passive [suicidal ideation], [danger to self], [danger to others], head banging, destruction of property due to denied access... the behaviors can last a couple of hours or the whole day depending on whether [R1] is not able to have to do the task requested[,] i.e.[,] brush teeth, do homework... Risk Assessment Details: Suicide... Admits... 01/11/2024... Does the individual have current or past difficulties with anger management? Yes... [parent] reported [R1] becomes verbally and physically aggressive with denied access, set expectations of daily hygiene, and anxiety... Assessment/Diagnosis... Autistic disorder... Profound intellectual disabilities..." 3. A review of facility documentation revealed an "Incident, Accident or Death Report," dated December 13, 2024 which detailed an incident which took place on December 11, 2024. The report stated, "[R1] was pacing in the house... staff attempted to redirect [R1] back to task, but [R1] ignored staff completely... [R1] did not complete any form of morning hygiene... staff noted [R1] has been wearing the same outfit for days... [R1] asked for a break... staff noticed [R1] became increasingly upset kicking the fence/attempting to break the locks, swearing and yelling... staff went back outside where [R1] was seen punching [R1's] head with [R1's] fists over thirty times... after 30 minutes [R1] transitioned inside with staff... but when learning [R1] could not have a preferred item [R1] eloped outside screaming, crying, and hitting self... [R1] laid on the ground coughing up blood... as staff called crisis mobile and TPD, [R1] continued to bang head on rocks ten times... EMTs arrived advising [R1] to be seen at a medical center... Before escalation [R1's] mood was depressed/anxious..." 4. In an exit interview, E1, O1, O2, O3, O4, O5, and O6 reviewed the findings and no additional documentation or statements were provided. This is a repeated deficiency from the complaint investigation conducted on November 21, 2024.


summary: Complaint - 11/21/2024

raw_content: An on-site investigation of complaints AZ00219023 and AZ00218647 was conducted on November 21, 2024 and the following deficienies were cited :

evidence: Based on documentation review, record review and interview, the administrator failed to ensure an admitted resident's behavioral health issue and treatment needs were within the behavioral health residential facility's scope of services. The deficient practice posed a health and safety risk as R1 and R2 were actively a danger to other residents.

findings: A.A.C. R9-10-101(31) "Behavioral health inpatient facility" means a health care institution that provides continuous treatment to an individual experiencing a behavioral health issue that causes the individual to: Have a limited or reduced ability to meet the individual's basic physical needs; Suffer harm that significantly impairs the individual's judgment, reason, behavior, or capacity to recognize reality; Be a danger to self; Be a danger to others; Be persistently or acutely disabled, as defined in A.R.S. \'a7 36-501; or Be gravely disabled. A.A.C. R9-10-101(36) "Behavioral health residential facility" means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: a. Limits the individual's ability to be independent, or b. Causes the individual to require treatment to maintain or enhance independence. 1. A review of the facility's policies and procedures revealed a section titled "ASSESSMENT AND INTERVENTION (AIC) BEHAVIORAL HEALTH RESIDENTIAL FACILITY PROGRAM DESCRIPTION." The program description contained a section titled AIC Scope which stated, "Assessment and Intervention (AIC) program has been established to fill the need for a Level II community- based program for the care and treatment for seriously emotionally disabled children who would otherwise be in higher levels of care. The program has a capacity to serve up to eight children, male or female, between the ages of 8-17. Referral issues are reviewed prior to a client's placement to ensure that those issues will not impact negatively on clients already placed at AIC. Staff are expected to circulate among clients so that clients are not left unattended for more than fifteen minutes during waking hours ...Admission Criteria: Appropriate candidates and circumstances are included in the Inclusionary and Exclusionary Criteria. Exclusionary Criteria:...Members with medical complexities exceeding the facility's ability to safely manage their care. Members who are exhibiting behaviors that are unable to be safely managed in the program setting ..." 2. A review of R1's medical record revealed a "Comprehensive Assessment" dated October 31, 2024 which stated, "Presenting Concerns ...[R1] continues to seek BH treatment to help address challeges with aggressive behaviors and trauma. [R1] is reported to react on impulse ...has a hard time controlling [R1's] anger in the moment ...[R1] lived with grandmother up until July when [R1] had to be hospitalized due to aggressive behaviors ....Risk Assessment Details:...Homicide ...The client indicated homicidal ideation. The client also states existence of a homicidal plan ...The client states client has attempted to do harm to others and that this attempt was an impulsive act ...Plan/attempt description: Has expressed the reaction [R1] feels toward other when upset or when other make him upset ...Risk: Suicide, Current: Admits, Property, Current: Admits, Homicide, Current: Admits ..." 3. A review of R2's electronic medical record revealed a "Comprehensive Assessment" dated November 14, 2024 which stated: "Presenting Issues:...Member was reported as having the following behaviors: Verbal and physical aggression. Anger management issues of fighting in school. Making statements of "I am going to kill you." Per member these behaviors were first noticed two months ago when member was starting fights in school when member was taken into custody after officers had come to [R2's] home and found guns ...Per member, they explode and assault individuals that disrespect them. Member reported these behaviors last until they "handle business ..." Member is reported as exhibiting verbal and physical aggression. Member exhibits behaviors multiple times a week due to environment and they can occur simultaneously depending on environment ...Member reported being in treatment for ADHD since they were 9 years old and denied being diagnosed with anything else ...Member has a probation officer due to aggressive behaviors and charges ...Member has a significant history of fights in school and placement ...Member escalates violently with immediate threat to self and others. Member attempts to provoke others to fight consistently through the day ... " 4. Further review of R2's medical record revealed an "Incident, Accident or Death Report" dated November 19, 2024 which detailed an incident which took place on November 17, 2024. The report stated, "...During afternoon, [R2] and peer [R1] were excluding peer [R3] from the activity, using profanity to antagonize him about his mental abilities ...[R3] stands up and member started to flinch and posture at [R3] with [R2's] fists. While this is happening, member proceeded to say to [R3], "what are you gonna do pussy? You gonna have a tantrum? Square up bitch, I'll fuck you up." Writer stepped in between both members directing them to walk away. Both the member and peer walked away, but not too long after, Member throws beans that were prepared for lunch at peer from across the kitchen. Member then turns around and comes back through the opposite side by running through the dining room/living room area and immediately runs towards [R3] while writer was trying to verbally deescalate [R3]. Writer slipped on beans several times while attempting to separate members. Member punched [R3] several times in the head, back, and neck, and pushed [R3] onto the couch where [R2] put [R3] into a choke hold. [R3] was also defending [R3's self] by punching the member back. Members entire arm was wrapped around [R3's] neck while [R2] squeezed. Writer pushed their hand underneath members arm and pulled up. Member let go after 20 seconds, staff #2 guided member outside. " 5. Further review of R2's electronic medical record revealed a "tis progress note" dated November 21, 2024 which stated, "Member continued typical behaviors and language ...Member had a peer get into their space and swatted their hand out of the way. Peer reported that member also slapped them in the face but this was not witnessed by counselor ...Member was addressed by police with a report of holding peer to the ground at night. Member became assaultive and combative with police claiming to be a crip, assaulting officers twice, refused to be compliant during detainment ...Member was attempting to kick and obtain officers weapon while in restraints and had to be removed in full restraints with several units dispatched. P: Discharge member and notify supervisor of incident. " 6. In an interview, E1 reported R2 was arrested from the facility on November 17, 2024 and was returned to the facility later on the same day. E1 acknowledged R2's behavioral issues continued to negatively impact other clients and other residents were harmed by R2. E1 reported R2 was arrested again earlier on the day of the inspection, November 21, 2024. E1 reported the facility accepts high acuity residents because the facility has at least two qualified staff members on-site at all times. However, E1 acknowledged that residents who posed a danger to themselves and others were admitted to the facility.

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as residents' rights were violated.

findings: 1. A review of R1's medical record revealed an "Incident, Accident or Death Report" dated November 11, 2024. The report detailed an account of an incident which took place between R1 and E4 on November 4, 2024 and stated: "...I walked towards the education room where this writer witnessed a peer on the roof of our education room and member inside our garage hitting the walls and floor with a broken tree branch. I asked them if they wanted to share what was going on and they proceeded to explain how mistreated they feel by a staff member and how horrible [E4] makes them feel. Member reported being forced to pick up a dirty underwear from one of [R1's] peers by said staff on 11/4 and after letting [E4] know it was not [R1's] underwear but roommate's underwear, [R1] claims [E4] responded by saying, "I don't care you're going to pick it up ...[R1] didn't share this incident with staff until 11/11 when [R1] mentioned, during education, staff told [R1] and [R1's] peer to 'shut up.'...Members stated that staff replied by saying 'While you are here at AIC, you do not have any rights.' Members mentioned staff also made a comment referring to members as 'little bitches bitching.' This writer spoke to both members and assured them we would look into it ...Actions taken and/or recommended: Supervisor was made aware of allegations against staff by other staff who were dealing with the escalated member ...Supervisor conducted interviews of staff and members regarding claims of abuse. Supervisor documented all statements and will follow up with director and HR regarding the findings of the incident." 2. In an interview, E1 reported E4 was placed on administrative leave and removed from the facility schedule while the human resources department conducted an investigation into E4's conduct. E1 reported E1 did not have access to the results of the investigation and acknowledged that based on the resident accounts detailed, residents were not treated with dignity, respect, and consideration.

rule: A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or treatment, or verbally or physically interact with any other resident that may present a threat to the resident's health or safety, based on the other resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, and personal history.

evidence: Based on record review and interview, the administrator failed to ensure a resident did not share a space with another resident that may present a threat to the resident's health or safety, based on the other resident's documented diagnosis and personal history. This deficient practice posed a risk as R2 posed a physical safety risk to R3 and other residents.

findings: 1. A review of R2's electronic medical record revealed a "Comprehensive Assessment" dated November 14, 2024 which stated: "Presenting Issues:...Member was reported as having the following behaviors: Verbal and physical aggression. Anger management issues of fighting in school. Making statements of "I am going to kill you." Per member these behaviors were first noticed two months ago when member was starting fights in school when member was taken into custody after officers had come to [R2's] home and found guns ...Per member, they explode and assault individuals that disrespect them. Member reported these behaviors last until they "handle business ..." Member is reported as exhibiting verbal and physical aggression. Member exhibits behaviors multiple times a week due to environment and they can occur simultaneously depending on environment ...Member reported being in treatment for ADHD since they were 9 years old and denied being diagnosed with anything else ...Member has a probation officer due to aggressive behaviors and charges ...Member has a significant history of fights in school and placement ...Member escalates violently with immediate threat to self and others. Member attempts to provoke others to fight consistently through the day ..." 2. A review of R3's electronic medical record revealed a "Comprehensive Assessment" dated November 11, 2024 which contained a section titled "Trauma History" that stated, "Mom reported that member suffered physical abuse by moms ex husband in 2017. Mom reported that member was sexually assaulted in their previous group home ..." The assessment also contained a section titled "Present Concerns" which stated, "...Member was reported as having the following behaviors: Verbal and physical aggression, passive SI, DTS, DTO, headbanging, destruction of property due to denied access ...There are reported behaviors of self-harming and suicidal ideations with member banging their head on the floor and hitting self in the head ...Member has history of DTS and DTO last hurting themselves in July of 2024 ...Member does not have DDD or high needs case management but is in need of this ..." R3's assessment also contained a section titled "Assessment/Diagnosis" which listed the following diagnoses: "Z59.1 Inadequate housing, F43.25 Adjustment disorder w mixed disturb of emotions and conduct, F84.0 Autistic disorder, F73 Profound intellectual disabilities." 3. Further review of R3's medical records revealed an "Incident, Accident or Death Report" dated November 19, 2024 which detailed an incident which took place on November 17, 2024. The report stated, "During morning, [R3] was excluded from activity by peers. Member walked away from the table nonverbal and asked staff if [R3] could go into [R3's] room. Member was given an alternate activity as he was reminded of expectations and points. Member was given Legos to use and was separated from the rest of the group next to the staff office. Member was targeted by [R2] where [R2] came up to member unprovoked and started stepping in [R3's] bin of Legos. Member became upset, grunting, screaming, hitting [R3's] head with [R3's] fists, hitting the fireplace, kicked the box of Legos across the room and threw the plastic lid, and threw lunch items at peers. [R2] continued to instigate and posture towards member then ran up behind member and writer, who was trying to verbally de-escalate member. [R2] started to punch member in [R3's] head, back and neck. [R2] then started to choke [R3]. Members face was turning blue, writer slid arm underneath peers' arm to release the squeeze. [R3] eventually let go and was guided out of the building with the rest of the group. Member started to throw up on the floor and expressed that [R3's] having trouble breathing. Staff did breathe exercises with member, but member was having a hard time following as [R3] kept on hyperventilating. TPD was notified and paramedics came on site to assess member. Member did not need any emergency treatment after this. Member has two large scratches on the right side of [R3's] neck and one on the left side under [R3's] chin. When members guardian was notified (1155), they did say they want to press charges on peer ...Staff followed proper prompts but the action from the member were not able to be prevented physically until [R2] attached [R2's] peer ..." 4. In an interview, E1 reported R2 was arrested after the aforementioned incident. However, E1 reported R2 was returned to the facility later the same day (November 17, 2024) and was not discharged at this time. 5. Further review of R2's electronic medical record revealed a "tis progress note" dated November 21, 2024 which stated, "Member continued typical behaviors and language ...Member had a peer get into their space and swatted their hand out of the way. Peer reported that member also slapped them in the face but this was not witnessed by counselor ...Member was addressed by police with a report of holding peer to the ground at night. Member became assaultive and combative with police claiming to be a crip, assaulting officers twice, refused to be compliant during detainment ...Member was attempting to kick and obtain officers weapon while in restraints and had to be removed in full restraints with several units dispatched. P: Discharge member and notify supervisor of incident." 6. In an interview, E1 reported R2 acknowledged R2 presented a threat to R3's - and other residents - health and safety, based on the residents' documented diagnosis and personal history. E1 reported R2 was arrested again earlier on the day of the inspection and would be discharged from the facility.

rule: F. An administrator shall ensure that: 1. A personnel member whose job description includes the ability to use an emergency safety response: b. Completes training required in subsection (F)(1)(a): ii. At least once every 12 months after the date the personnel member completed the initial training;

evidence: Based on record review and interview, the administrator failed to ensure a personnel member, whose job description included the ability to use an emergency safety response (ESR), completed training required in R9-10-716.F.1.a. at least once every twelve months after the personnel member completed the original training, for one of four sampled personnel members whose job description included the ability to use an ESR. This deficient practice posed a safety risk if a resident was harmed the an improperly administered ESR.

findings: 1. Further review of R3's medical records revealed an "Incident, Accident or Death Report" dated November 19, 2024 which detailed an incident which took place on November 17, 2024. The report stated, "...Member was targeted by [R2] where [R2] came up to member unprovoked and started stepping in [R3's] bin of Legos. Member became upset, grunting, screaming, hitting [R3's] head with [R3's] fists, hitting the fireplace, kicked the box of Legos across the room and threw the plastic lid, and threw lunch items at peers. [R2] continued to instigate and posture towards member then ran up behind member and writer, who was trying to verbally de-escalate member. [R2] started to punch member in [R3's] head, back and neck. [R2] then started to choke [R3]. Members face was turning blue, writer [E5] slid arm underneath peers' arm to release the squeeze ...Staff followed proper prompts but the action from member were not able to be prevented physically until he attacked his peer ..." 2. A review of E5's personnel record revealed a job description which indicated E5 was hired as a "Behavioral Technician." The job listed one of the "Job Responsibilities" as "Implements treatment goals, including acquisition skills, replacement skills, and deceleration skills, safety/crisis plans, crisis management techniques and utilizes interventions based on Positive Behavioral Support ..." 3. Further review of E5's personnel record revealed a training which indicated E5 completed training for "QBS Safety Care: De-escalation Training Modules" on October 9, 2023. 4. In an interview, E1 reported all facility staff receive training in the use of emergency safety response (ESR), and that E5 used an ESR on R2 in the aforementioned incident as a last resort. E1 reported the facility uses QBS Safety Care curriculum for this training and all staff receive annual refresher trainings. E1 acknowledged E5 did not complete the training required in R9-10-716.F.1.a. at least once every twelve months.

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

evidence: Based on 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. The deficient practice posed a risk as construction was actively occurring while residents lived on the premises.

findings: 1. The Compliance Officer arrived at BH1618 at approximately 11:30 am. The Compliance Officer observed several trucks parked and six men in the process of conducting renovations at BH1618. O1 reported the men were construction workers in the process of installing new cabinets and flooring in the home. O1 reported no facility staff or residents were present, as staff took residents away from the home during the day while construction was taking place. 2. During a facility tour with E1, the Compliance Officer observed the following: -The dishwasher, stove, and stove vent were removed from the wall in the facility's kitchen; -All of the furniture in the facility's common areas was pushed into the center of the living room and a drop cloth was placed in the front hall to the right of the furniture; -The sink and mirror in the shared hallway bathroom on the east side of the facility had been removed, leaving exposed plumbing, electrical, and concrete; -Tile flooring in the western hallway of the facility had been removed, leaving exposed concrete; -A resident bedroom at the west end of the facility had a bed flipped on its side and a half finished floor with exposed concrete; -The door to another resident bedroom at the end of the western hallway of the facility was ripped off of its top hinge and had a hole in its center; and -The wall of the shared common room across from the aforementioned bedroom had four large holes in a panel of the wall. 3. In an interview, E1 reported the facility's five current residents left the facility every morning at 8:00 AM and returned at 5:00 PM. E1 reported the construction workers on site arrived after residents left the facility each morning, then cleaned up all equipment and left before residents returned to the facility in the evening. E1 acknowledged the facility's premises and equipment were not maintained in a condition which allowed the premises and equipment to be used for their original purpose while renovations were taking place.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: b. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure the premises and equipment were cleaned and if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a potential safety risk if residents were exposed to debris and respiratory irritants, as construction was occurring while residents lived on the premises.

findings: 1. A review of facility policies and procedures revealed a policy titled "Cleanliness of Physical Plant, Equipment & Environment " which stated, " Intermountain will ensure that all residential facilities and equipment used and operated byIntermountain Centers for Human Development, Inc., and its Affiliates (Intermountain Centers) will be clean, safely maintained and meet the needs of the residents being served ...4. It is the responsibility of the residential personnel to ensure that daily cleaning is done by the residents (resident's bedroom, share of bathroom and daily chore). If it is not done by the resident, the personnel in charge of the residential facility is responsible for ensuring it is clean and disinfected if necessary. Intermountain facilities must be clean, healthy, and safe environments at all times ... " 2. The Compliance Officer arrived at BH1618 at approximately 11:30 am. The Compliance Officer observed several trucks parked and six men in the process of conducting renovations at BH1618. O1 reported the men were construction workers in the process of installing new cabinets and flooring in the home. O1 reported no facility staff or residents were present, as staff took residents away from the home during the day while construction was taking place. 3. The Compliance Officer observed all of the furniture in the facility's common areas was pushed into the center of the living room and a drop cloth was placed in the front hall to the right of the furniture. The drop cloth was covered in dirt and dust. The Compliance Officer observed the flooring had been removed from the hallway and one resident bedroom on the west side of the house. Exposed concrete was on the ground beneath the removed flooring. The compliance officer observed dust and bits of drywall and concrete scattered throughout the house in the areas where renovations were taking place. 4. The Compliance Officer observed piles of dirty bedding and clothing on the ground in two of the resident bedrooms connected to the hallway on the east side of the facility. 5. In an interview, E1 reported the facility's five current residents left the facility every morning at 8:00 AM and returned at 5:00 PM. E1 reported the construction workers on site arrived after residents left the facility each morning, then cleaned up all equipment and left before residents returned to the facility in the evening. E1 acknowledged the facility's premises and equipment were not cleaned while renovations were taking place.


summary: Complaint;Compliance (Annual) - 10/3/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00212499 and AZ00216860 conducted on October 3, 2024:

inspection_type: Complaint;Compliance (Annual)

rule: 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: a. Provide the services in the behavioral health residential facility's scope of services, b. Meet the needs of a resident, and c. Ensure the health and safety of a resident.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on the facility premises with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident and ensure the health and safety of a residents. 1. A review of E7's, E8's, E9's, E10's, E11's, and E12's personnel records revealed documentation of the verification of qualifications including skills and knowledge was not available for review. 2. A review of E6's and E13's personnel record revealed documentation of completed orientation wasnot available for review. 3. A review of E11's personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review. 4. A review of facility documentation revealed an incident report dated in September 2024. The incident report stated "...[E11] approached the drive through gate with another peer. [R2] was screaming and crying for [E11]. [E11] approached [R2]. [R4] awoled [sic] through the window of Puesta and tried to charge [R2]. Peer #2 was holding [R4] through the window. [E8] came out from Puesta and instead of blocking [R4] or peer #2 staff approached [R2] and began body checking [R2]. [R2] was making statements like 'say what you said in front of [E11], you won't you [expletive] [expletive]' 'you're not supposed to put hands on members do what you were doing in front of [E11].' [E11] had to step between [E8] and [R2]...[R2] stated that [E8] was antagonizing [R2] and making statements like 'fight someone your own size punk' 'I'm going to let peer #2 beat your [expletive]' '[E8] put hands on me [E11].' [R2] expressed feeling scared of [E8]..." 5. In a joint interview, E1, E2, and E3 acknowledged the findings.

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for six of seven behavioral health technicians sampled. The deficient practice posed a risk if a personnel member was not qualified to work in a health care institution.

findings: 1. A review of E7's, E8's, E9's, E10's, E11's, and E12's personnel records revealed documentation of the verification of qualifications including skills and knowledge was not available for review. 2. In a joint interview, E1, E2, and E3 acknowledged documentation of E7's, E8's, E9's, E10's, E11's, and E12's verification of qualifications including skills and knowledge was not available for review.

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

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed orientation, for two of nine personnel members sampled. The deficient practice posed a risk if a personnel member was not qualified to work in a health care institution.

findings: R9-10-101.155. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution. 1. A review of E6's and E13's personnel record revealed documentation of completed orientation was not available for review. 2. In a joint interview, E1, E2, and E3 acknowledged documentation of E6's and E13's completed orientation was not available for review.

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

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained to include documentation of A.R.S. \'a7 36-411(A)(C)(1), for one of nine personnel members sampled. The deficient practice posed a risk if E11 was a danger to vulnerable population.

findings: A.R.S. \'a7 36-411(C)(1) Owners shall make documented, good faith efforts to: 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; 1. A review of E11's personnel record revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review. 2. In a joint interview, E1, E2, and E3 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C)(1) for E11 was not available for review.

rule: K. An administrator shall ensure that: 3. There is a daily staffing schedule that: a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members;

evidence: Based on documentation review and interview, the administrator failed to ensure there was a daily staffing schedule to indicate the name of each employee assigned to work, including on-call personnel members. The deficient practice posed a risk as there was no record to ensure a current behavioral health professional and registered nurse were on-call.

findings: 1. A review of facility documentation revealed daily staffing schedules dated from May 2024 to October 2024. However, the staffing schedules did not include the on-call behavioral health professional (BHP) or registered nurse (RN). 2. The Compliance Officer observed E3 correct the October 2024 schedule to include the on-call BHP and RN. 3. In a joint interview, E1, E2, and E3 acknowledged the daily staffing schedule did not include the on-call BHP or RN.

rule: A. An administrator shall ensure that: 2. At the time of admission, a resident or the resident's representative receives a written copy of the requirements in subsection (B) and the resident rights in subsection (E); and

evidence: Based on record review and interview, the administrator failed to ensure at the time of admission a resident or the resident's representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (E), for one of three current residents sampled.

findings: 1. A review of R2's medical record revealed documented evidence R2 received a written copy of the requirements in subsection (B) and the resident rights in subsection (E) was not available for review. 2. In a joint interview, E1, E2, and E3 acknowledged R2's representative did not receive a written copy of the requirements in subsection (B) and the resident rights in subsection (E).

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration, for one of three current residents sampled.

findings: 1. A review of facility documentation revealed an incident report dated in September 2024. The incident report stated "...[E11] approached the drive through gate with another peer. [R2] was screaming and crying for [E11]. [E11] approached [R2]. [R4] awoled [sic] through the window of Puesta and tried to charge [R2]. Peer #2 was holding [R4] through the window. [E8] came out from Puesta and instead of blocking [R4] or peer #2 staff approached [R2] and began body checking [R2]. [R2] was making statements like 'say what you said in front of [E11], you won't you [expletive] [expletive]' 'you're not supposed to put hands on members do what you were doing in front of [E11].' [E11] had to step between [E8] and [R2]...[R2] stated that [E8] was antagonizing [R2] and making statements like 'fight someone your own size punk' 'I'm going to let peer #2 beat your [expletive]' '[E8] put hands on me [E11].' [R2] expressed feeling scared of [E8]..." 2. In an interview, E1 stated a "staffing" was conducted with E8 and E8 was not terminated. 3 In a joint interview, E1, E2, and E3 acknowledged the administrator failed to ensure R2 was treated with dignity, respect, and consideration.


summary: Complaint - 6/26/2024

raw_content: An on-site investigation of complaint AZ00212257 was conducted on June 26, 2024 and the following deficiencies were cited :

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure policies and procedures were implemented to protect the health and safety of a resident which covered cardiopulmonary resuscitation training including the time-frame for renewal of cardiopulmonary resuscitation (CPR) training, for one of three personnel records sampled. The deficient practice posed a health and safety risk to residents as E2's CPR training had expired.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Staff Qualifications," reviewed December 2023. The policy stated "Staff providing in-person direct care services are required to show evidence of a valid, in-person CPR and First Aid certification upon hire and are required to continuously maintain certification throughout term of employment." 2. A review of E2's personnel record revealed documentation of cardiopulmonary resuscitation training which expired February 2024. 3. In an interview, E2 reported E2 had not renewed E2's cardiopulmonary resuscitation training. 4. In a joint interview, O3 and O4 acknowledged E2's documentation of CPR training had expired February 2024. 5. In an interview, O3 reported personnel members are notified by Dayforce [software company] and their managers prior to their CPR training expiring. 6. In a joint interview, O1, O2, O3, and O4 acknowledged E2's CPR training expired February 2024. 7. In an interview, O1 acknowledged E2's CPR training was not renewed within compliance of facility policies and procedures.

rule: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while a resident is receiving services from a behavioral health residential facility's employee or personnel member, the administrator shall: 2. Report the suspected abuse, neglect, or exploitation of the resident: b. For a resident under 18 years of age, according to A.R.S. § 13-3620;

evidence: Based on documentation review, record review, and interview, the administrator failed to report suspected abuse of a resident under 18 years of age, according to A.R.S. \'a7 13-3620. The deficient practice posed a health and safety risk to residents as personnel members witnessed the abuse of a resident.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Reporting & Responding to Abuse & Neglect," reviewed November 2021. The policy stated "If abuse, neglect, or exploitation was suspected to have occurred on premises or while the member was receiving services, staff should: b. Contact the appropriate adult or child welfare agency and/or local law enforcement." 2. A review of facility documentation revealed security camera footage with video from June 17th at 7:53 pm of abuse from E1 to R1. The footage lasted approximately eighteen seconds. At approximately 0:12 seconds into the video, R1 began walking down the hallway and E1 followed and at 0:14 seconds R1 extends R1's hand to touch the wall. At approximately 0:15 seconds, E1 extended E1's right arm and placed E1's hand on R1's right upper arm and appeared to have pushed R1 to the middle of the hallway, with enough force to cause R1 to stumble. 3. A further review of facility documentation revealed a security camera footage with video from June 17th at 8:03 pm of abuse from E1 to R1. The footage lasted approximately twenty-two seconds. At approximately 0:10 seconds in, E1 appeared to extend E1's left forearm to deter R1 from leaving the room and E1's left hand is seen grabbing R1's forearm. At approximately 0:12 seconds in, R1 tried to exit the room again and E1 forcefully extended E1's and pushed R1 towards the middle of the room. 4. A review of R1's medical record revealed an incident report dated June 20th for an incident which occurred on June 17th. The incident report included a summary of events from 5:30 pm until 8:45 pm. However, the incident report did not include mention or documentation of R1's abuse. 5. In an interview, R1 reported E1 grabbed R1's right arm while R1 was in the hallway. 6. In a joint interview, O1 and O2 reported as part of their quality management program, they frequently reviewed security camera footage to which they came across "alarming" footage of E1, in reference to the aforementioned security camera footage. O1 reported due to the severity of the footage, E1 was going to be placed on a corrective action plan and O2 was currently in the process of working on the plan. O1 reported E1 had not been informed of the corrective action yet. O1 and O2 reported being unaware of the requirement of reporting suspected abuse in compliance with A.R.S. \'a7 13-3620. 7. In a secondary interview, O1 reported E2 reported an incident with a two-person hold to O2, in which O2 then reviewed the security camera footage and saw the aforementioned video's. 8. In an interview, E2 reported reviewing R1's incident report which mentioned a two-person hold was used. E2 reported staff did not communicate the incident in the group chat which led E2 to review security camera footage. E2 then reported the incident to O2. 9. In a joint interview, O1, O2, and O3, acknowledged the aforementioned security camera footage revealed suspected abuse of a resident. O1, O2, and O3 acknowledged E4, E5, E2, O1, O2, and upper management did not report the suspected abuse in compliance with A.R.S. \'a7 13-3620.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel's members skills and knowledge were documented, for one of six four personnel records sampled. The deficient practice posed a health and safety risk as E1 was suspected of abusing a resident and the Department could not verify if E1's skills and knowledge were verified prior to providing physical health or behavioral health services.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Orientation and Training," reviewed March 2024. The policy stated "VI. Process....D. Documentation of the staff member's competency skills and training hours are documented in the employee's personnel file." 2. A review of E1's personnel record revealed no documentation of verification of skills and knowledge. 3. In a joint interview, O3 reported the verification of skills and knowledge are kept at the facility and not in personnel records. O1 reported looking for E1's documented verification of skills and knowledge. However, no documentation was provided for review. 4. In a joint interview, O1, O2, and O3 acknowledged no documentation of E1's verification of skills and knowledge was provided for review.

rule: B. An administrator shall ensure that: 2. A resident is not subjected to: a. Abuse;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident was not subjected to abuse.

findings: 1. A review of facility documentation revealed security camera footage with video from June 17th at 7:53 pm of abuse from E1 to R1. The footage lasted approximately eighteen seconds. At approximately 0:12 seconds into the video, R1 began walking down the hallway and E1 followed and at 0:14 seconds R1 extends R1's hand to touch the wall. At approximately 0:15 seconds, E1 extended E1's right arm and placed E1's hand on R1's right upper arm and appeared to have pushed R1 to the middle of the hallway, with enough force to cause R1 to stumble. 2. A further review of facility documentation revealed a security camera footage with video from June 17th at 8:03 pm of abuse from E1 to R1. The footage lasted approximately twenty-two seconds. At approximately 0:10 seconds in, E1 appeared to extend E1's left forearm to deter R1 from leaving the room and E1's left hand is seen grabbing R1's forearm. At approximately 0:12 seconds in, R1 tried to exit the room again and E1 forcefully extended E1's and pushed R1 towards the middle of the room. 3. In an interview, R1 reported E1 grabbed R1's right arm when R1 was in the hallway. 4. In a joint interview, O1 and O2 reported as part of their quality management program, they frequently reviewed security camera footage to which they came across "alarming" footage of E1, in reference to the aforementioned security camera footage. O1 reported due to the severity of the footage, E1 was going to be placed on a corrective action plan and O2 was currently in the process of working on the plan. O1 reported E1 had not been informed of the corrective action yet. 5. In a joint interview, O1, O2 and O3 acknowledged the aforementioned security camera footage appeared to reveal E1 abusing R1.

rule: B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident was not subjected to restraint.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Seclusion/Restraint," reviewed May 31, 2024. The policy stated "Restraint - any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely or restrict the member's freedom of movement and is not a standard treatment for the member's condition...... Policy....Seclusion and restraint are high-risk interventions that must be used to address emergency safety situations only when less restrictive interventions have been determined to be ineffective...." Further review of facility documentation revealed an emergency safety response policy and procedure which reported "Safety-Care" as a current emergency safety response training protocol within the facility. 2. A review of facility documentation revealed security camera footage with video from June 17th at 8:00:38 from the kitchen. The video lasts approximately eleven seconds. At approximately 0:03 seconds in, E5 and E6 enter the bottom right of the camera frame already in a two person hold with R1. R1 had E5 with arms wrapped around one arm and E6 wrapped around R1's second arm. R1 was being restrained and forcefully moved from the kitchen to the living room and off to the east hall. 3. A further review of facility documentation revealed security camera footage with video from June 17th at 8:00:46 from the east hall. The video lasts approximately fifteen seconds. Starting at approximately 0:04 seconds in, E5 and E6 have R1 in a two person hold and are seen moving R1 into an isolated room and standing in the doorway to keep R1 in the room. 4. A review of R1's medical record revealed an incident report dated June 20th from an incident which occurred on June 17th. The incident stated "Staff put member into a two-person safety hold to guide the member to [their] room." 5. A review of Safety Care by QBS website at www.qbs.com revealed "Frequently Asked Questions (FAQ)." The FAQ stated "4. What physical procedures are included in the Safety-Care curriculum? Safety-Care provides physical safety and physical management procedures that are designed to be simple and safe.... Physical management (restraint) procedures are designed to be infrequent, safe, and practical. They include a 1-person and 2-person standing hold (including management options if the individual drops to the floor), two 2-person transports, and a chair hold." 6. In a joint interview, O1, O2 and O3 reported Safety Care was the current emergency safety response training and procedure for the facility. O1 reported restraints are not allowed or used at the residential facility. O1 reported the aforementioned policy and procedure titled "Seclusion/Restraint" was a company wide policy and does not apply to residential facilities. O1 acknowledged there was no documentation provided to imply the provided policy and procedure did not apply to the behavioral health residential facility. O1 reported the aforementioned security camera footage displayed a properly trained 2-person hold. O1 acknowledged the 2-person hold R1 was placed in reduced the ability for R1 to move R1's arms and restricted R1's freedom of movement. O1 acknowledged reducing the ability for R1 to move R1's arms and restricting R1's freedom of movement was restraining R1. O1 acknowledged relocating the resident from one room to another while in a 2-person hold was also restraining R1.


summary: Complaint;Compliance (Annual) - 9/29/2023

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00200582 conducted on September 29, 2023:

rule: 36-420.01. 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 manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery for two of two personnel sampled. The deficient practice posed a risk to the physical health and safety of a resident.

findings: 1. A review of E7's (hire date May 30, 2023) personnel record revealed E7 completed orientation, however, no documentation of E7's completion of initial fall prevention and fall recovery training was provided. 2. A review of E8's (hire date July 10, 2023) personnel record revealed E8 completed orientation, however, no documentation of E8's completion of initial fall prevention and fall recovery training was provided. 3. During an interview, E6 acknowledged there was no documentation provided indicating E7 or E8 had completed an initial training program for fall prevention and fall recovery.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure at least one personnel member who was present at the behavioral health residential facility during hours of operation of the behavioral health resident facility had first-aid and cardiopulmonary resuscitation (CPR) training, for one of two personnel members sampled. The deficient practice posed a risk if the personnel member did not have proper training to perform life saving techniques in the event of an emergency. 1. A review of a staff schedule for August and September 2023 revealed E8 worked alone from 9:00 PM to 7:00 AM on August 15, 16, 22, 29 adn 30, 2023, and on September 5, 6, 13, 16, 20, 23 and 27, 2023. 2. A review of E8's personnel record revealed a first-aid card which expired on July 21, 2023. E8's personnel record did not contain documentation of current first-aid training. 3. In an interview, E1 acknowledged there were times when no personnel present at the facility had current first-aid training.

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

evidence: Based upon record review and interview, the administrator failed to ensure that a medical practitioner performed a medial history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documented the medial history and physical examination or nursing assessment in the resident's medial record within 72 hours after admission, for one of two resident's sampled.

findings: 1. A review of R2's medical record revealed evidence of a medical history and physical exam or nursing assessment within 30 calendar days before admission or 72 hours after admission was not available for review. Based on R2's date of admission, this document was required. 2. In an interview, E1 acknowledged R2's medical history and physical exam or nursing assessment was not available for review.

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

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

findings: 1. During a tour of the facility, the Compliance Officer observed a common bathroom available to guests and residents to use. The bathroom contained a shower which included grab bars attached to the wall. The Compliance Officer also observed grab bars mounted behind and next to a toilet. 2. In another bathroom used by residents, the Compliance Officer observed a metal towel bar mounted to the wall with screws. When the Compliance Officer applied considerable downward pressure, the towel bar did not give easily. 3. During an interview, E1 acknowledged that the grab bars and towel bar posed a potential ligature hazard.


summary: Complaint - 4/20/2023 - 4/21/2023

raw_content: An on-site investigation of complaint AZ00189133 and AZ00188790 was conducted on April 20 and 21, 2023, and the following deficiency was cited :

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

evidence: Based on observation, record review, interview, and documentation review, the administrator failed to ensure a resident did not 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. The deficient practice posed a health and safety risk to residents.

findings: 1. A review of R1's (date of admission October 11, 2022) medical record revealed a document titled, "Comprehensive Assessment," dated October 11, 2022. The assessment contained a section titled "Risk Assessment," which indicated R1 had a "suicidal plan" with R1's "level of intent" self reported as "7 on a scale of 1 to 10." The Risk Assessment also indicated R1 had a previous suicide attempt "and impulsively tried to slit [R1's] throat." The assessment also contained a section titled "Past Risk and Alerts," which documented R1 as having a history of "cutting [R1's] arms." 3. A review of incident reports regarding R1 revealed a report dated October 25, 2022, which indicated facility personnel "found pencil sharpener razors and a metal rod in [R1's] room." 4. In an interview, E1 reported it was believed R1 obtained the razor from a hand held pencil sharpener used during education and creativity activities. E1 summarized R1 kept a pencil sharpener, disassembled it and kept the razor within. E1 advised personnel members are responsible for handing out the pencil sharpeners and recovering them from residents, however there is no system in place to document and control which resident receives a pencil sharpener, and if the sharpener is returned. 5. In an interview, E1, E2 and E3 individually acknowledged that R1 had access to equipment and materials that presented a threat to R1's safety based upon R1's documented diagnosis, treatment needs, developmental levels and personal history.


facility_name: FLORENCE CRITTENTON SERVICES OF ARIZONA, INC

summary: Complaint - 11/24/2025

raw_content:
An on-site complaint investigation of complaint 00147769 was conducted on November 24, 2025.

The allegation that a person shall not establish, conduct or maintain in this state a health care institution or any class or subclass of health care institution unless that person holds a current and valid license issued by the department specifying the class or subclass of health care institution the person is establishing, conducting or maintaining, per A.R.S. § 36-407.A. was unable to be substantiated and no deficiency was cited.


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 Council on Accreditation valid from June 30, 2023 through June 30, 2026. If the health care institution's accreditation report is not valid for the entire licensure period, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.

inspection_type: Compliance (Annual)


summary: Complaint - 9/4/2024

raw_content: An on-site investigation of complaint AZ00215534 was conducted on September 4, 2024 and the following deficiency was cited :

rule: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure residents were treated with dignity, respect, and consideration.

findings: 1. A review of facility documentation revealed a document titled "Job Description" for "Title: Behavioral Health Technician." The job description contained a section titled "Primary Duties and Essential Functions" which stated, "...4) Provides direct client care while considering safety, client rights, cleanliness, and comfort. Ensures a nurturing environment is maintained by implementing established procedures and communicating daily with clients ...e. Provide clients with positive guidance, role modeling, re-direction, and behavior management, while modeling appropriate boundaries and relationships ...9) Assists in de-escalation and stabilization of clients in critical situation ..." 2. A review of E2 ' s and E3 ' s personnel records revealed E2 and E3 were hired as behavioral health technicians (BHTs). E2 ' s and E3 ' s personnel records contained documents titled "Residential Program Training, Orientation and Competency" which included a checklist of orientation and skills and knowledge verification items for E2 and E3. The checklist included educational units on "Client Rights" and "Appropriate Boundaries." Both units were completed by E2 and E3. 3. A review of R1 ' s medical record revealed a document titled "Florence Crittenton Internal Investigation Report." The report included a "Summary Timeline of Events" which stated, "Tuesday, September 3, 2024, On Sunday, September 1st, 2024, Youth Program Supervisor [NAME] notified [E5], [R1 ' s] grandmother called the Campus Lead ' s phone, stating, "[R1] reported staff pushed [R1] and hit [R1]. The following question was asked to youth:..Is there anything else you would like us to know? [R1] stated, ' Yes, staff physically touched me. They pushed me and touched my leg. [E4] or [E3] pushed me; I didn ' t want to be outside ...Follow Up: After reviewing the footage, [R1] can be observed opening the door for [R1 ' s] peer who is not resident in cottage 2. [E2] attempted to block the doorway from the other youth entering the cottage. [R1] backs up into [E2 ' s] arm, and [R1] immediately lifts [E2 ' s] arm into the air and repositions it on the door frame away from [R1]. [R1] is then observed bumping into [E3], which results in [E3] slightly shifting [E3 ' s] balance and moves away from [R1]...[E5] made a report to Department of Child Safety Hotline on 9/3/24 and spoke to [O1]. [O1] informed [E5] this report does not meet the criteria for a report. However, O1 will cross reference this information to Department of Health for review." 4. The Compliance Officer observed video footage from the incident discussed in the "Internal Investigation Report" discussed in finding three. The Compliance Officer observed the facility ' s account of the incident was accurate and observed no signs of E2 or E3 pushing or hitting R1. However, the Compliance Officer did observe R1 touched E2 ' s arm and bumped into E3 during what appeared to be an attempt for R1 to allow R2 to enter the cottage. The Compliance Officer then observed R1 left the cottage. The video did not have sound, so it was not possible to determine if E2 and E3 verbally assisted in de-escalating and stabilizing R1 and R2 in this situation. 5. In an interview, E1 reported E2 and E3 had not yet been interviewed regarding the incident with R1. E1 acknowledged the situation had escalated and R1 was physically touched by E2. E1 reported R1 was uncomfortable being touched, and though unintentional, this may be considered a violation of R1 ' s rights.


summary: Complaint - 2/20/2024

raw_content: An on-site investigation of complaint AZ00206577 was conducted on February 20, 2024 and no deficiencies were cited.


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 Council on Accreditation valid from February 14, 2020 through February 29, 2024. 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 - 5/8/2023

raw_content: An on-site investigation of complaint AZ00194719 was conducted on May 8, 2023 and no deficiencies were cited :


summary: Complaint - 4/18/2023

raw_content: An on-site investigation of complaint AZ00192607 was conducted on April 18, 2023 and no deficiencies were cited.


facility_name: THE U - TURN FOUNDATION

summary: Compliance (Annual) - 11/12/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on November 12, 2025

rule: R9-10-719.A.4. Food Services A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 4. A registered dietitian is employed full-time, part-time, or as a consultant; and

evidence: Based on record review and interview, the administrator failed to ensure a registered dietitian was employed full-time, part-time, or as a consultant. The deficient practice posed a health risk as the facility did not have a registered dietitian available to address dietary needs.

findings: 1. A review of E2's personnel record revealed E2 was a registered dietitian. 2. A review of E2's personnel record revealed a document titled "Contract for U Turn Foundation," dated November 1, 2024. The agreement stated, "Contract effective for 12 months from date on this contract." 3. In an interview, E6 reported E6 was unable to locate an updated contract. 4. In an exit interview, the findings were discussed with E6, and no additional statements or documentation were provided.

rule: R9-10-720.B.2. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 2. The disaster plan required in subsection (B)(1) is reviewed at least once every 12 months;

evidence: Based on documentation review and interview, the administrator failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a health and safety risk if personnel members were unable to ensure the health and safety of residents during a disaster, emergency, or unexpected event.

findings: 1. A review of facility documentation revealed a disaster plan. The plan included a document titled "Disaster Plan Annual Review Document." The annual review was completed on October 28, 2024. 2. In an interview, E6 reported no annual review updates to the disaster plan since October 28, 2024. 3. In an exit interview, the findings were reviewed with E6, and no additional comments or statements were provided regarding the findings.


summary: Complaint;Compliance (Annual) - 10/25/2024

raw_content: No deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00205384 conducted on October 25, 2024.


summary: Compliance (Annual) - 10/17/2023

raw_content: No deficiencies were found during the on-site compliance inspection conducted on October 17, 2023. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.


facility_name: STEP TWO RECOVERY CENTER

summary: Compliance (Annual) - 12/9/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on December 9, 2025.


summary: Complaint - 1/6/2025

raw_content: A Notice of Noncompliance was sent to the licensee on December 13, 2024, due to failure to meet the Terms in the Settlement Agreement based on the inspection conducted on November 22, 2024. The Department provided notification that the licensee must cure or correct the violations. On January 6, 2025, an on-site inspection to verify the cure or corrections revealed the following new deficiencies:

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

rule: 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: a. Provide the services in the behavioral health residential facility's scope of services, b. Meet the needs of a resident, and c. Ensure the health and safety of a resident.

evidence: Based on observation, record review, documentation review and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk if the facility was unable to meet the needs of the residents and ensure the resident's health and safety.

findings: 1. During a facility tour, the Compliance Officers observed a casita located in the backyard on the facility premises, separate from the primary living area for residents. The casita contained a privacy room for counseling, and an office area. The office area contained a space designated for medication storage. 2. In an interview, E1 reported residents are provided assistance in the self-administration of medication in the office area. 3. A review of R3's medical record revealed a medication administration record (MAR). The MAR revealed R3 was provided assistance in the self administration of medication for Ibuprofen 200 mg on January 3, 2025 at 2:31 AM. 4. A review of the facility's daily staffing schedules revealed E10 was the only staff member who worked on January 3, 2025 from 12-10 (AM or PM was not indicated). 5. In an interview, E1 reported E10 was the only staff working from 12:00 AM to 10:00 AM on January 3, 2025. E1 reported staff provide assistance in the self-administration of medication in the casita, and if one staff member is working, staff assist the residents with medication in the casita, and residents are left unattended inside of primary living area. 6. A review of facility documentation revealed an incident report, dated April 17, 2024. The incident report stated "DESCRIPTION OF MEDICATION ERROR, OVERDOSE, OR ADVERSE REACTION (Including events leading up to incident: Resident [R4] witnessed resident [R5] intranasally ingesting Cephalexin 500mg. Resident asked to participate. Resident [R4] intranasally ingested medication...WITNESSES (If name release is prohibited by law, list identifier code): [R5], [R4], [R6], [R7]...ACTION TAKEN TO PREVENT A SIMILAR INCIDENT FROM OCCURRING IN THE FUTURE: Residents will be brought individually to the group room to receive assist in self administration of medication. An in-service training of all medication policies and procedures will be done with all personnel who assist in self administration of medication ..." 7. In an interview, E1 reported R5 obtained Cephalexin 500 mg when R5 was provided assistance in the self administration of medication, and R5 left the medication in R5's cheek. E1 reported R4 and R5 intranasally ingested the medication in a shared bathroom. 8. In an exit interview, the findings were reviewed with E1 and no further statements were made.

rule: 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;

rule: C. An administrator shall ensure that a resident's medical record contains: 6. If applicable, documented general consent and informed consent for treatment by the resident or the resident's representative;

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 observation, record review, documentation review, and interview, the administrator failed to ensure an individual whose behavioral health issue limits the individual's ability to function independently, received continuous protective oversight. The deficient practice posed a risk to residents who required continuous protective oversight due to their limited ability to function independently.

findings: 1. During a facility tour, the Compliance Officers observed a casita located in the backyard on the facility premises, separate from the primary living area for residents. The casita contained a privacy room for counseling, and an office area. The office area contained a space designated for medication storage. 2. In an interview, E1 reported residents are provided assistance in the self-administration of medication in the office area. 3. A review of R3's medical record revealed a medication administration record (MAR). The MAR revealed R3 was provided assistance in the self administration of medication for Ibuprofen 200 mg on January 3, 2025 at 2:31 AM. 4. A review of the facility's daily staffing schedules revealed E10 was the only staff member who worked on January 3, 2025 from 12-10 (AM or PM was not indicated). 5. In an interview, E1 reported E10 was the only staff working from 12:00 AM to 10:00 AM on January 3, 2025. E1 reported staff provide assistance in the self-administration of medication in the casita, and if one staff member is working, staff assist the residents with medication in the casita, and residents are left unattended inside of primary living area. 6. In an exit interview, the findings were reviewed with E1 and no further statements were made.

evidence: Based on observation, record review, documentation review and interview, the administrator failed to ensure a resident did not have access to any materials to present a threat to the resident's health or safety based on the resident's documented personal history. The deficient practice posed a risk as residents had access to harmful materials while admitted into a behavioral health residential facility.

findings: R9-10-101.32. "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. 1. During a facility tour, the Compliance Officer observed, in an unlocked kitchen drawer, five knives, varying in length. 2. A review of R2's (a current resident) record revealed a behavioral health assessment, dated in 2024. The behavioral health assessment stated "Suicide Screen ...History of self-harm behaviors? Resident reported 3 suicide attempts...Resident reported history of self-harm via cutting and burning ...Resident reported last cutting a couple of weeks ago." 3. A review of facility documentation revealed an incident report, dated August 11, 2024. The incident report stated "DESCRIPTION OF INCIDENT (Including events leading up to incident): Resident was in the shower and used a soda bottle cap to commit self-injury at approximately 1:00 a.m. on 8/10/24...[R8] ACTION TAKEN (Including individuals or entities notified & date and time of notification): Personnel [E9] went to check on resident when resident was done showering and noticed that [R8] had teary eyes...Resident admitted to personnel that [R8] had self-injured in the shower. Resident committed to not self-injuring again ..." 4. A review of R8's (a former resident) record revealed a behavioral health assessment, dated in 2024. The behavioral health assessment stated "Risk Assessment ...Explain all Behaviors considered a Danger Toward Self or Others (e.g. Suicidal, Homicidal, Aggression/violence, Self-Injury, Dangerous Substance Use, etc.) Resident reported struggling with self-harm via cutting at age 12. Resident reported cutting 1 month ago and had months of refraining from acting out prior to recent behavior. Resident reported trying to overdose on laced THC carts in middle school. Resident reported cutting to try and die. Resident never was hospitalized ..." 5. In an exit interview, the findings were reviewed with E1 and no further statements were made.

rule: B. An administrator shall ensure that counseling is: 2. Provided according to the frequency and number of hours identified in the resident's treatment plan, and

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

evidence: Based on observation, record review and interview, the administrator failed to ensure the facility was free from a condition or situation to cause a resident or other individual to suffer physical injury. The deficient practice posed a self-harm risk to R2.

findings: 1. During a facility tour, the Compliance Officer observed, in an unlocked kitchen drawer, five knives, varying in length. 2. A review of R2's medical record revealed a behavioral health assessment, dated in 2024. The behavioral health assessment stated "Suicide Screen ...History of self-harm behaviors? Resident reported 3 suicide attempts...Resident reported history of self-harm via cutting and burning ...Resident reported last cutting a couple of weeks ago." 3. In an exit interview, the findings were reviewed with E1 and no further statements were made.

rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: k. Has a clothing rod or hook in the bedroom designed to minimize the opportunity for a resident to cause self-injury.

evidence: Based on observation, record review and interview, the administrator failed to ensure a resident bedroom had a clothing rod or hook in the bedroom designed to minimize the opportunity for a resident to cause self-injury. The deficient practice posed a risk to the physical health and safety of a resident.

findings: 1. During a facility tour, the Compliance Officer observed five resident bedrooms that contained a closet with metal bracket support hooks holding up light-weight PVC pipe being used as a closet rod. The support hooks did not give way when the Compliance Officer applied downward pressure. 2. A review of R2's medical record revealed a behavioral health assessment, dated in 2024. The behavioral health assessment stated "Suicide Screen ...History of self-harm behaviors? Resident reported 3 suicide attempts...Resident reported history of self-harm via cutting and burning ...Resident reported last cutting a couple of weeks ago." 3. In an interview, E1 reported to be unaware the hooks were of concern and reported to be under the impression the rods were safe because they were made of lightweight PVC. 4. In an exit interview, the findings were reviewed with E1 and no further statements were made. This is a repeat deficiency from an inspection conducted on February 16, 2023.