summary: Complaint - 12/16/2025

raw_content:
The following deficiencies were cited at the time of the unannounced, on-site State Complaint Investigation conducted December 16, 2025, pursuant to the rules found in 9 A.C.C. 10, Article 3: Behavioral Health Inpatient Facilities for the following intakes:

00150310

Healthcare Compliance Officer
December 18, 2025

rule: R9-10-303.C.1.f.i-iv Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that: f. Cover cardiopulmonary resuscitation training including: i. The method and content of cardiopulmonary resuscitation training, 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: R9-10-303.C.1.f.i Based on review of policies and procedures, personnel records, and staff interview, the Department determined that the administrator failed to ensure personnel members engaged in an in-person Cardiopulmonary Resuscitation (CPR)/First Aid course. This deficient practice can result in patient harm if personnel members are unable to appropriately assist someone needing CPR/First Aid.

findings: Review of policy titled “CPR and First Aid Training”, Policy #HR015, last reviewed 12/4/2024, revealed “...Initial CPR and First Aid training must be completed in person…The training must include demonstration of the individual's ability to perform CPR….” A request was made for evidence of a policy requirement regarding demonstration of the individual’s ability to perform CPR for CPR/First Aid courses taken after their initial course. None was provided. Review of personnel records on 12/16/2025, revealed the following: Employee #3 completed a CPR/First Aid course on 4/4/2025, however, it was conducted by NationalCPRFoundation, which was confirmed to be an online course. Employee #7 completed a CPR/First Aid course on 9/1/2025, however, it was conducted by NationalCPRFoundation, which was confirmed to be an online course. Employee #8 completed a CPR/First Aid course on 10/10/2025, however, it was conducted by NationalCPRFoundation, which was confirmed to be an online course. Employee #9 completed a CPR/First Aid course on 12/3/2025, however, it was conducted by NationalCPRFoundation, which was confirmed to be an online course. A request was made on 12/16/2025, for Employee #3, #7, #8, and #9’s in-person skills demonstration. None were provided. Employee #5 confirmed in an interview conducted on 12/16/2025, that Employee #3, #7, #8, and #9 completed their CPR/First Aid courses through NationalCPRFoundation and confirmed this was an online course.

rule: R9-10-307.A.2 Admission; Assessment A. Except as provided in R9-10-315(E) or (F), an administrator shall ensure that: 2. A patient is admitted on the order of a medical practitioner or clinical director;

evidence: Based on documentation request, review of medical records and staff interview, the Department determined that the administrator failed to ensure patients were admitted on the order of a medical practitioner or clinical director. This deficient practice poses the risk of patients not receiving the appropriate level of care and resulted in 5 out of 5 patients without admission orders.

findings: On 12/16/2025, a request was made for a policy that requires an admission order from a medical practitioner or clinical director upon a patient’s admission to the licensed facility. None was provided. During medical record review on 12/16/2025, a request was made for evidence of an admission order from a medical practitioner or clinical director for Patient #1, #2, #3, #4, and #5. None were provided. Employee #3 and #4 confirmed in interviews conducted on 12/16/2025, that there was no documented evidence of an admission order from a medical practitioner or clinical director for Patient #1, #2, #3, #4, and #5.


state: AZ

facility_name: Montare Behavioral Health

summary: Complaint - 2/5/2025

raw_content: No deficiencies were cited at the time of the unannounced, on-site State Complaint Investigation conducted February 5, 2025, pursuant to the rules found in 9 A.C.C. 10, Article 3: Behavioral Health Inpatient Facilities for the following intakes: AZ00222116 Healthcare Compliance Officer February 5, 2025

inspection_type: Complaint


summary: Complaint - 8/5/2024

raw_content: The following deficiencies were cited at the time of the unannounced, on-site State Complaint Investigation conducted August 5, 2024, pursuant to the rules found in 9 A.C.C. 10, Article 3: Behavioral Health Inpatient Facilities for the following intakes: AZ00205162 AZ00206148 Kylie Hake Healthcare Compliance Officer August 12, 2024

rule: R9-10-303. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that: m. Cover quality management, including incident reports and supporting documentation;

evidence: Based on review of medical records, facility policies and procedures, and interview, the Department determined the administrator failed to ensure policies and procedures were implemented for incident reporting. This deficient practice poses the potential risk that investigations may not take place and not be assessed which can result in patient harm. *This is a repeat deficiency from the Complaint Survey on December 19, 2023

findings: Review of policy titled "Sentinel Events and Reporting" dated November 6, 2023, requires "...Adverse Event is a patient safety event that results in harm to a patient...1. Any employee...who is aware of an incident that may be an Adverse Event...is responsible for contacting the primary physician and the House Supervisor and for completing an Incident Report...designee will immediately compare the events reported against the Sentinel and Never Event criteria...2. The Quality and Risk Management department will begin the investigation immediately...." Review of policy titled "Level of Observation" dated January 23, 2024, revealed "...The psychiatrist shall order observation level at time of admission and may change the level of observation if the patient's condition warrants a change...Q 5-minute observation...a. As ordered by a Psychiatrist...." Review of policy titled "Room Searches" dated January 23, 2024, requires "...When there is reasonable cause to believe a client may possess an item that is potentially hazardous and (sic) room search may be conducted...Room searches should be done for specific client rooms where there is reasonable cause to believe the client may possess an item that is potentially dangerous...." Interview with Employee #1 and review of electronic communication on February 4, 2024, revealed notification to Medical Director and Leadership regarding incident with Patient #2. Review of Patient #2's medical record revealed document titled "Nursing Screen & Assessment" dated January 30, 2024, that revealed "...Initiate Q15 precautions...." completed by a Registered Nurse. A request was made for a Psychiatrist's order that details Patient #2's observation level at time of admission, per policies and procedures. None was provided. A request was made for a Psychiatrist's order that reviews Patient #2's observation level following the incident of Patient #2 harming themselves, per policies and procedures. None was provided. Review of Patient #2's medical record revealed document titled "Medical Progress Note"s dated February 3, 2024, that revealed details of the incident of Patient #2 harming themselves by kicking a bench outside and sent off site for further assessment. Review of Patient #2's medical record revealed document titled "Unusual Incident/Injury Report" dated February 4, 2024, that revealed various details of the incident and transportation to a hospital via EMS following an assessment by an RN. A request was made for an internal investigation conducted by facility, per policies and procedures, for the incident with Patient #2. None was provided. Interview with Employee #1 and review of electronic communication revealed notification to Medical Director and Leadership regarding incident with Patient #1 on January 11, 2024. Review of Patient #1's medical record revealed "Physician Assistant Order" dated, January 5, 2024, that revealed "...All staff to monitor patient q 5 for safety...." A request was made for an order from a Psychiatrist, per policies and procedures. None were provided. A request was made for a Psychiatrist's order that details Patient #1's observation level at time of admission, per policies and procedures. None was provided. Review of Patient #1's medical record revealed "Medical Progress Note"s dated January 6, 2024 - January 10, 2024, that revealed Patient #1 remained on Q5 checks until discharge date of January 11, 2024. Review of Patient #1's medical record revealed "Unusual Incident/Injury Report" dated January 11, 2024, that revealed various details of the incident including"...Patient #1 reports she has been purging all medications for the past 8-10 days. Staff has been aware of this...and pt was put on 30 minute lockout post meals and pt remains on q5 observation...." Review of Patient #1's medical record revealed "Therapeutic Intervention Note" dated January 11, 2024, that revealed "...Writer assisted BHT in transporting this client to ED...due to client's self harming...." A request was made for an internal investigation conducted by facility, per policies and procedures, for the incident with Patient #1. None was provided. Employee #1 confirmed the following in an interview conducted on August 5, 2024: No internal investigation or room search was conducted, according to policies and procedures, for Patient #1 and #2, a Psychiatrist had not ordered levels of observation at admission for Patient #1 and #2, and a Psychiatrist had not ordered/reviewed levels of observation following the incidents with Patient #1 and #2, per policies and procedures.

rule: R9-10-110. Modification of a Health Care Institution_x000D_ A. A licensee shall submit a request for approval of a modification of a health care institution when planning to make:_x000D_ 1. An addition or removal of an authorized service;_x000D_ _x000D_ _x000D_

evidence: Based on a review of Arizona Revised Statutes (A.R.S.), applications of licensure, medical records, staff interview, and observation, the Department determined the administrator failed to ensure a request for approval of a modification of a healthcare institution when planning to make an addition of an authorized service was provided to the Department as required by rule. This deficient practice poses the potential risk to patient health and safety if the facility is providing care for services they have not been approved for.

findings: Review of A.R.S. revealed: "...A licensee shall submit a request for approval of a modification of a health care institution when planning to make an addition or removal of an authorized service...." Review of the initial compliance survey for State Licensure dated October 21, 2021 and the modification survey on December 20, 2023, revealed the facilities approved scope of services, however, the following service was not listed on either survey: Clinical Laboratory Services. Review of Patient #4's medical record on August 5, 2024, revealed Patient #4 received blood glucose monitoring via fingerstick on July 21, 2024, July 22, 2024, and July 27, 2024. Review of Patient #5's medical record on August 5, 2024, revealed Patient #5 received blood glucose monitoring via fingerstick on July 22, 2024, July 23, 2024, and July 24, 2024. Interview with Employee #1 and Employee #10 on August 5, 2024, revealed the facility has provided other Clinical Laboratory services within the last 12 months. Observation on tour on August 5, 2024, revealed a Clinical Laboratory Improvement Amendment (CLIA) certificate with an expiration date of July 29, 2023. Employee #1 and #10 confirmed in an interview on August 5, 2024, that the facility was providing Clinical Laboratory Services and that the CLIA certificate expired on July 29, 2023.

rule: R9-10-311. Patient Rights D. A patient 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:

evidence: Based on observation and interview, the Department determined the administrator failed to ensure patient privacy was protected while in treatment within the licensed space. This deficient practice poses the potential risk of patients being viewed in treatment areas and having their rights to privacy in treatment violated.

findings: Observation on tour on August 5, 2024, revealed multiple rooms in a portable unit on the licensed facility's property. Further review revealed a patient receiving counseling/therapy services in one of the rooms in the portable unit with no privacy screen/covering on the window. Employee #1 confirmed during an interview on August 5, 2024, that the patient was receiving counseling/therapy services during the facility tour and there was no privacy screen/window covering on the window.

rule: R9-10-323. Environmental Standards A. An administrator shall ensure that: 1. The premises and equipment are: b. Free from a condition or situation that may cause a patient or other individual to suffer physical injury;

evidence: Based on review of policies and procedures, observation and interview, the department determined the administrator failed to ensure the premises were free from a condition that could cause a patient to suffer physical injury. This deficient practices poses the potential risk of patient harm when patients are exposed to ligature risks and other items that could cause injury.

findings: Review of policy titled "Client Belongings and Valuables", dated January 23, 2024, revealed "...The following items shall NOT be permitted on the unit...d. Cell phones...f. Electronic equipment....ii. Admission staff will ask the client to EMPTY their pockets. Do a check of ALL personal belongings for medications, valuables, and contraband. iii. Remove any...contraband and catalogue clearly in front of the client and secure in designated container(s)...." Observation during facility tour on August 5, 2024, revealed various items in patient bedrooms that includes, but is not limited to: Multiple and/or All Rooms: Phone/Electronic chargers and a keyboard plugged in. Room 2: Exposed screws on the wall. Room 4: Electrical outlet cover that was chipped and loose. Room 7: A hole in the bathroom wall that contained broken tile with sharp edges, command hooks on the wall, multiple lighters on the dresser, and various rolled smoking products on the dresser. Room 8: Screw missing in the electrical outlet. Room 9: A vaping device on the nightstand. Multiple and/or All Patient Bathrooms: Toilet plumbing exposed and not contained in a tamper resistant enclosure. Further observation on tour revealed a patient talking on his cell phone. A request was made for a full list of contraband. None was provided. A request was made for evidence of room searches. None was provided. Employee #1 confirmed in an interview conducted on August 5, 2024, that the above items/actions were observed during the facility tour and that room searches are only conducted when there is reason a reasonable cause to believe a patient possess a potentially hazardous item. Employee #1 also confirmed that the findings above may not be all inclusive, as some patient bedrooms/bathrooms were occupied during survey.

rule: R9-10-323. Environmental Standards B. An administrator shall ensure that: 1. Smoking tobacco products is not permitted within a behavioral health inpatient facility; and

evidence: Based on review of policies and procedures, observation, and interview, the Department determined that the administrator failed to ensure smoking products is prohibited and not accessible within the facility. This deficient practice poses the potential risk of physical harm to patients due to exposure to disease causing toxins and ignition sources near combustible chemicals.

findings: Review of policy titled "Smoking Policy", dated January 23, 2024, revealed "...It is the policy of...to not allow smoking of any kind or tobacco use inside the facility, including vapes and e-cigarettes. Designated smoking areas are outside and acceptable only during break and meal periods...Smoking (including e-cigarettes, vape, tobacco, or others) is not allowed inside of the facility...No open flames are allowed...." Observation on tour on August 5, 2024, revealed multiple lighters and various rolled smoking products on the dresser in Room 7. Further observation revealed a vaping device on the nightstand in Room 9. Employee #1 confirmed in an interview on August 5, 2024, that patients are allowed to hold smoking products and lighters in their rooms.

rule: R9-10-324. Physical Plant Standards B. An administrator shall ensure that: 5. A patient bathroom complies with the following: b. Contains: iii. Nonporous surfaces for shower enclosures and slip-resistant surfaces in tubs and showers;

evidence: Based on observation and interview, the Department determined that the administrator failed to ensure patient bathrooms contained slip-resistant surfaces in showers. This deficient practice poses the potential risk of patients slipping in the shower and causing physical injury.

findings: Observation on August 5, 2024, revealed multiple patient bathrooms that did not contain slip resistant surfaces in the shower. Employee #1 confirmed in an interview on August 5, 2024, that the observed shower surfaces, and others, were not slip-resistant.

rule: R9-10-324. Physical Plant Standards B. An administrator shall ensure that: 5. A patient bathroom complies with the following: f. If a grab bar is provided, has the space between the grab bar and the wall filled to prevent a cord being tied around the grab bar;

evidence: Based on observation and interview, the Department determined that the administrator failed to ensure the grab bars in the patient bathroom were filled to prevent a cord being tied around the grab bar. This deficient practice poses the potential health and safety risk for patients including possible death.

findings: Observation on tour on August 5, 2024, revealed multiple grab bars in Room 2 that did not have the space between the grab bar and the wall filled. Employee #1 confirmed in an interview on August 5, 2024, that the grab bars in Room 2 were not filled.


summary: Other - 12/20/2023

raw_content: No deficiencies were cited at the time of the desktop modification of services survey conducted on 12/20/2023. Pursuant to the rules found in 9 A.A.C. 10, Article 3: Behavioral Health Inpatient Facilities, the Department is approving the Behavioral Health Inpatient Facility for the following scope of services: Physical Health Services Behavioral Health Services Restraint Medication Services Food Services Christine Pereira, PsyD Healthcare Compliance Manager

inspection_type: Other


summary: Compliance (Annual) - 12/18/2023 - 12/19/2023

raw_content: The following deficiencies were found during the State Compliance survey conducted on December 18 and 19, 2023, utilizing the rules found under Article 3, Behavioral Health Inpatient Facilities. The facility is approved to continue to provide the following services: Physical Health Services, Behavioral Health Services, Restraint, Medication Services, and Food Services. Christine D. Pereira, PsyD Healthcare Compliance Manager Maggie Farley, RN Healthcare Compliance Surveyor

inspection_type: Compliance (Annual)

rule: R9-10-303. Administration A. A governing authority shall: 7. Except as provided in subsection (A)(6), notify the Department according to § A.R.S. § 36-425(I) when there is a change in the administrator and identify the name and qualifications of the new administrator.

evidence: Based on review of the facility's policies, licensing file and interview, the Department determined that the administrator failed to ensure the Department was notified of multiple changes in the Administrator since the facility commenced operation. By not notifying the Department of the current active Administrator, the Department does not have a current representative of the facility to ensure communications are received such as fingerprint clearance denials, changes to rules and regulations, and other regulatory contacts.

findings: The Department's licensing file for the facility revealed that Employee #26 was listed as the facility administrator. Policy titled "Qualifications and Responsibilities of the Administrator" revealed "...In the event of a change in the Administrator state and federal regulatory agencies will be notified per established guidelines...." Interview with Employee #1 and Employee #2 on December 18, 2023, revealed that neither of them knew who Employee #26 was or how long ago they were employed at the facility. The facility's current Administrator was Employee #1 and confirmed in an interview on December 18, 2023, that the facility did not notify the Department of changes in Administration since the original licensure Administrator, nor was the Department provided with the name and qualifications of the current administrator.

rule: R9-10-304. Quality Management An administrator shall ensure that: 3. The report required in subsection (2) and the supporting documentation for the report are maintained for at least 12 months after the date the report is submitted to the governing authority.

evidence: Based on review of facility policy and procedure, facility documents, and the lack of presentation of any additional documentation prior to the exit conference and interview, the Department determined that the agency failed to maintain evidence of a 12 month report to the governing authority related to Quality Management, which poses a potential risk to the health and safety of patients if the facility did not submit a report to governing authority evaluating their services by identifying and tracking trends affecting patient care.

findings: Policy titled "Performance Improvement" states "...The QAPI Plan will be reviewed and revised on an annual basis and an Action Plan will be developed for areas of improvement. The management team will review the quality improvement activities conducted during the year...." A copy of the facility Quality Management report that is provided to the governing body for the prior 12 months of their Quality Management activities was requested. No Governing Body meeting minutes or Quality Management report was provided. Employee #2 confirmed during an interview conducted on December 18, 2023, that the facility Quality Management report reviewed by the governing authority was not available to review.

rule: R9-10-311. Patient Rights A. An administrator shall ensure that: 2. At the time of admission, a patient or the patient's representative receives a written copy of the requirements in subsection (B) and the patient rights in subsection (D); and

evidence: Based on review of medical records and interview, the Department determined that the Administrator failed to ensure that patient's received a written copy of the patient rights at outlined in the rules. This deficient practice results in patients not being informed of their right and could result in patient rights violations as patients are not aware of their rights.

findings: Patient #1, 2, 3, 4, 5, 6, & 7's medical record revealed a copy of a patient rights that was missing the following patient rights afforded to patients in this article: The patient's right to be free from Abuse, Neglect, Coercion, Manipulation, Sexual Abuse, Sexual Assault, and Retaliation. Evidence that the above patients were notified of these rights was requested. None was provided. Interview with Employee #2 and #5 during medical records review on December 18 and December 19, 2023, confirmed, the patient rights patients that patients are provided during the intake process does not match the rights outlined in this article.

rule: R9-10-312. Medical Records A. An administrator shall ensure that: 6. A patient ' s medical record is protected from loss, damage, or unauthorized use.

evidence: Based on facility tour and interview, the Department determined that the administrator failed to ensure a patient's medical record is protected from unauthorized use. This deficient practice violates a patients right to privacy.

findings: A tour of the facility on December 18, 2023, revealed a drawer in the patient milieu room that did not have any locking mechanism. Upon opening the drawer, paperwork was revealed. The first set of paperwork appeared to be patient homework sheets with patient names, goals and accounts of their day. The second paperwork were handwritten notes, with patient names and clinical assessments of the patients such as "less anxiety" etc. A policy regarding medical record storage and access was requested. None was provided. Interview with Employee #2 during the tour on December 18, 2023, confirmed that the medical records found in an unsecured area in a drawer that does not lock were completed by one of the facility's therapists and patients and should be in secure medical records.

rule: R9-10-315. Behavioral Health Services A. An administrator shall ensure that: 3. An acuity plan is developed, documented, and implemented for each unit in the behavioral health inpatient facility that: a. Includes: ii. A policy and procedure stating the steps the behavioral health inpatient facility will take to obtain or assign the necessary personnel members to address patient acuity;

evidence: Based on review of facility policy and procedure, document review, and interview, the Department determined that the administrator failed to ensure policies and procedures were developed, documented, and implemented outlining steps the facility would take to obtain or assign necessary personnel members to address patient acuity which poses a risk to the health and safety of patients if adequate staff are not added when needed to provide patient services.

findings: Policy titled "Program Description-Scope of Services" was provided and states "All units are staffed with qualified Clinical staff according to the staff-to-resident ratios established for each unit, which are 1:6 during waking hours and 1:10 during sleeping hours...Staff assigned to monitor of supervise residents will be clearly listed on the assignment sheets...." A request for patient acuity, unit staffing and assignment was requested. A nursing schedule with 1 RN during the day and 1 RN during the night was provided. No patient acuity policy, additional staffing assignment sheets or schedules were provided. Review of medical records revealed several patients on higher levels of observation and no evidence was produced that staffing levels were increased to meet the higher acuity patients needs for higher levels of observation. Employees #2 and 5, confirmed in an interview conducted on December 19, 2023, that the facility did not have patient acuity and staffing assignment sheets to provide.

rule: R9-10-322. Emergency and Safety Standards B. 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 review of facility documents, policy, and interview, the Department determined that the administrator failed to ensure that the facility's disaster plan was reviewed once every 12 months. This deficient practice poses a patient safety risk as the plan may no longer be appropriate or effective in the event of a disaster at the facility.

findings: The facility "Emergency Operations Plan and Response Plans" was dated May 1, 2022. It had a signature page for approval by the "CEO, Governing Board, CMO, Nursing, Director Clinical Services, Human Resources, and Plant Operations Safety Officer." The page was not signed by any of the listed members. A disaster plan dated within the last 12 months or evidence of review and revision was requested. None was provided. Employee #2 confirmed that the "Emergency Operations Plan and Response Plans" had not been reviewed annually.

rule: R9-10-322. Emergency and Safety Standards B. An administrator shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

evidence: Based on review of facility documents, and interview, the Department determined that the administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. This deficient practice poses a patient safety risk if staff are not trained and competent in implementing the facility's disaster plan in the event of an internal or external disaster at the facility. This is a repeat deficiency from Event #8HE711 on November 22, 2022.

findings: A policy regarding disaster drills was requested. None was provided. A request for all drills in the past year was requested on December 18, 2023 of Employee #2, #5 and #27, and again on December 19, 2023 of Employee #1 and Employee #2. None were provided. Employee #2 confirmed on December 19, 2023, that a disaster drill for staff has not been provided.

rule: R9-10-322. Emergency and Safety Standards B. An administrator shall ensure that: 5. An evacuation drill for employees and patients: a. Is conducted at least once every six months; and

evidence: Based on observation, and interview, the Department determined that the administrator failed to ensure evacuation drills were conducted at least once every six months. Failure to ensure evacuation dills are conducted at least once every six months poses a patient safety risk staff do not appropriately respond in the event of an emergency at the facility.

findings: A policy regarding evacuation drills was requested. None was provided. A request for all drill in the past year was requested on December 18, 2023 of Employee #2, #5 and #27, and again on December 19, 2023 of Employee #1 and Employee #2. None were provided. Employee #2 confirmed on December 19, 2023, that evidence of evacuation drills has not been provided.

rule: R9-10-322. Emergency and Safety Standards C. An administrator shall: 1. Obtain a fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal,

evidence: Based on a review of facility policy and interview, the Department determined that the administrator failed to ensure that a fire inspection was conducted within the last 12 months as established by their local fire department, which poses the potential risk of staff and visitor harm if a fire event should occur. This is a repeat deficiency from Event #8HE711 on November 22, 2022.

findings: A request was made for the last fire inspection. None was provided. Employee #2 and #26 confirmed on December 18, 2023, they did not have evidence of a fire inspection to provide.

rule: R9-10-323. Environmental Standards A. An administrator shall ensure that: 1. The premises and equipment are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

evidence: Based on facility tour observation, and employee interview the Department determined that the administrator failed to ensure that the premises and equipment is cleaned and disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. This deficient practice poses a risk to the health and safety of the patients when the facility is not cleaned and disinfected.

findings: A cleaning/disinfection policy was requested but never received. Observations on tour conducted on December 18, 2023 and again on December 19, 2023, revealed the following cleaning and disinfection issues: Patient bathroom vents were more than 75% of the ventilation holes were covered in dust and debris and could not be seen due to the buildup of debris. Employee #2, confirmed during the tour that the patient vents in patient bathrooms had pervasive debris that need to be addressed and cleaned.

evidence: Based on facility tour observation, and employee interview the Department determined that the administrator failed to ensure toilets and cabinets were properly installed in patient bathrooms to minimize and/or eliminate ligature risks. Failure to correctly install toilets and cabinets appropriately provide opportunities for patients to utilize these as tie off points thus presenting a health and safety risk for patients including possible death.

findings: A policy regarding ligatures was requested. None was provided. Observations on tour conducted on December 18, 2023, revealed patient bathrooms with metal plates from the toilet tank cover to the wall allowing for tie off points. The cabinets under the patient sinks in bathrooms were not secured shut and allowed access to plumbing. Furthermore, several that were secured shut, did not have tamper resistant screws and screws were observed not flush, missing or significantly out of the thread about to fall out. Employee #2 confirmed in an interview on December 18, 2023, that patient bathrooms had not been maintained in a manner to decrease patient safety risk.

rule: R9-10-323. Environmental Standards A. An administrator shall ensure that: 2. A pest control program that complies with A.A.C. R3-8-201(C)(4)is implemented and documented;

evidence: Based on a review of facility documents and interview, the Department determined that the administrator failed to ensure a pest control program that complies with A.A.C. R3-8-201(C)(4) is implemented and documented. This poses a risk of patients and staff being exposed to illnesses and infections caused by bacteria and diseases carried by pests. A contract, receipt or invoice for pest control services was requested. None was provided. Employee #2 confirmed in an interview on December 18, 2023, that evidence of a pest control program was not able to be provided at the time of survey.

rule: R9-10-324. Physical Plant Standards B. An administrator shall ensure that: 5. A patient bathroom complies with the following: g. Does not contain a towel bar, a shower curtain rod, or a lever handle that is not a specifically designed anti-ligature lever handle;

evidence: Based on facility tour, observation, and employee interview the Department determined that the administrator failed to ensure shower curtain rods that are specifically designed anti-ligature in patient bathrooms to minimize and/or eliminate ligature risks. Failure to have anti-ligature shower curtain rods provide opportunities for patients to utilize these as tie off points thus presenting a health and safety risk for patients including possible death.

findings: A policy regarding ligatures was requested. None was provided. Observation on December 18, 2023, revealed patient bathrooms with shower curtain rods that are standard tension rods and not specifically designed as anti-ligature. Employee #2 confirmed in an interview on December 18, 2023, that patient bathrooms had shower curtain rods that are standard tension rods and not specifically designed as anti-ligature.


summary: Complaint - 12/18/2023 - 12/19/2023

raw_content: The following deficiencies were found during the State Complaint survey conducted on December 18 and 19, 2023, utilizing the rules found under Article 3, Behavioral Health Inpatient Facilities for the following intakes: AZ00191248 AZ00199682 AZ00204401 Christine D. Pereira, PsyD Healthcare Compliance Manager Maggie Farley, RN Healthcare Compliance Surveyor

rule: R9-10-303. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that: h. Include a method to identify a patient to ensure the patient receives physical health and behavioral health services as ordered;

evidence: Based on review of policy and procedure, facility documents, medical records, and interview, the Department that the facility failed to ensure that (3) of (3) patients (Patients #6, #7 and #8) were under close observation as ordered. Failure to the follow the provider's order for close observation poses a potential risk to the health and safety of the patient including a patient engaging in self harm.

findings: The facility policy titled "Level of Observation" requires: "...The monitoring protocol can be increased as needed during the course of treatment if it is determined through clinical screening and assessment that the client requires increased monitoring to maintain the client's safety. Increased observation shall be ordered by the doctor. Observations can be increased to every fifteen minutes (Q15), every ten minutes (Q10), every five minutes (Q5), continuous line of sight, or one on one (1:1) monitoring based on the assessment of risk. ...." Patient #6 was ordered to be placed on "Q5" on February 24, 2023, at 10:15 p.m. due to self-injurious behavior. However, the first documented "Q5" rounds began February 25, 2023 at 11:55 a.m. Medical record documentation confirmed that patient was onsite and attending groups on the dates that no rounds were documented. Patient #7 was ordered to be placed on "Line of Sight" on December 13, 2023 due to suicidal ideation. Q5 checks were documented until December 18, 2023 at 10 a.m at which time Q15 checks began being documented. A request was made for a provider order discontinuing the checks. None were provided. The most recent provider order on December 15, 2023, stated "...Remain on line of sight precautions...." Medical record documentation confirmed that patient was onsite and attending groups on the dates that no rounds were documented. Patient #8 was ordered to be placed on "Q5" on October 29, 2023, due to suicidal ideation. Q5 checks were documented on October 29, 2023, but not on October 30 & 31, 2023 and not on November 1, 2023, and resumed being documented on November 2, 2023. Medical record documentation confirmed that patient was onsite and attending groups on the dates that no rounds were documented. Employee #5 confirmed during interviews conducted on December 18, & 19, 2023, that close observation forms were not available for the above dates.

rule: R9-10-303. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that: m. Cover quality management, including incident reports and supporting documentation;

evidence: Based on review of facility policy and procedure, incident reports, and employee interview the Department determined the Administrator failed to ensure policy and procedure was followed for completing incident reports. This deficient practice poses the potential risk to patient health and safety when incident reports are not reviewed timely for possible direct service and/or physical plant safety improvements.

findings: A policy regarding incident reporting was requested. None was provided. Review of patient medical records revealed Patient #6 and Patient #7 engaged in self harm incidents resulting in a hospital visit. Interview with Employee #5 on December 18, 2023, confirmed that both incidents should have resulted in an incident report being completed. Incident reports for Patient #6 & #7 were requested. None were provided. Employee #5 confirmed during an interview conducted on December 18, 2023, that the policy and procedure for completing incident reports was not followed for these two patients.

rule: R9-10-303. Administration C. An administrator shall ensure that: 4. Policies and procedures are available to personnel members, employees, volunteers and students; and

evidence: Based on observation and interview, the Department determined that the administrator failed to ensure policies and procedures are available to personnel members, employees, volunteers, and students. This deficient practice can result in patient harm if employees do not know how to handle certain situations or how to get information to handle incidents.

findings: Multiple requests for polices and procedures were made on December 18, 2023 and December 19, 2023. Employee #2 did not have access to medication policies. Employee #5 had to provide medication policies. Employee #5 did not have access to facility policies. No Employee provided facility policies during the course of the survey. Employee #2 and Employee #5 confirmed during an interview on December 18, 2023, that policies and procedures are not readily available to all personnel.

rule: R9-10-303. Administration E. An administrator shall provide written notification to the Department of a patient ' s: 2. Self-injury, within two working days after the patient inflicts a self-injury that requires immediate intervention by an emergency medical services provider.

evidence: Based on medical record review and interview, the Department determined that the administrator failed to notify the Department of Patient #6 & 7's self harm attempts that resulted in EMS (emergency medical services) being called to provide intervention and transportation to the local Emergency Department (ED).

findings: Patient #6 & #7's medical record indicated that the patient engaged in self harm resulting in EMS service being called and the patient being transported to the ED. A request for documented evidence that the Department had been notified of the incident was requested. None was provided. Employee #2 confirmed that the Department was not notified of the two patient's self harm requiring emergency medical services as required in the rules for Inpatient Behavioral Health Facilities for which the facility is licensed.

rule: R9-10-306. Personnel F. 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 review of facility policy and procedure, personnel records and interview, the Department determined the administrator failed to ensure that that require documentation of an individual's in-service education which poses the potential risk that employees are not completing appropriate annual training while providing medical services, nursing services, or health-related services to a patient. This deficient practice may result in a patient being subjected to abuse, neglect or harm.

findings: The facility policy titled "Orientation and Training " requires " ...Clinical/Nursing Staff will receive additional training...in at least the following areas...Suicide risk assessment...CPR...Documentation requirements .... " Documentation of training for Suicide Risk Assessment for Employees #21, 23, 24, and 25, was requested. None was provided. Documentation of Documentation Requirements training was requested for Employees #3, 5, 19, 20, 21, 22, 23, 24, and 25. None was provided. Interview with Employee #7 on December 19, 2023, confirmed that training's for Documentation and Suicide Risk Assessment had not been completed for the above employee's.

rule: R9-10-306. Personnel F. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: g. Cardiopulmonary resuscitation training, if required for the individual according to R9-10-303(C)(1)(e);

evidence: Based on review of facility policy and procedure, personnel records reviewed, and staff interview, the Department determined that the administrator failed to ensure that personnel records contained documentation of current cardiopulmonary resuscitation (CPR). This deficient practice poses a risk to patient's health and safety if the facility cannot verify that personnel members are trained to current CPR standards.

findings: The facility policy titled "Orientation and Training " requires " ...Clinical/Nursing Staff will receive additional training...in at least the following areas...Suicide risk assessment...CPR...Documentation requirements .... " Documentation of CPR training was requested for Employee #11, 12, 13, 14, 15, 16, 20, 23 & 25. None was provided. Interview with Employee #7 on December 19, 2023, confirmed that CPR training for the above individuals had not been completed.

rule: R9-10-306. Personnel H. An administrator shall ensure that: 1. A plan to provide orientation specific to the duties of a personnel member, an employee, a volunteer, and a student is developed, documented, and implemented;

evidence: Based on review of facility policy and procedures, personnel file review and interview, the Department determined the Administrator failed to ensure orientation specific to the duties of a personnel member, an employee, a volunteer, and a student is developed, documented, and implemented and that employees received orientation prior to providing patient care. This deficient practices poses the potential risk that staff would not be aware of the facility policies and procedures and be in compliance with their job descriptions. This deficient practice has the potential to cause patient harm if staff are not properly trained.

findings: Facility document titled "Orientation and Training" revealed: "...Montare Behavioral Health provides comprehensive orientation and training to meet all applicable accreditation, federal and state regulations......." Orientation documentation was requested for Employee #8, 11, 12, 13, 14, 15, and 16. None was provided. Employee #7, in an interview conducted on December 19, 2023, confirmed that personnel records for employees #8, 11, 12, 13, 14, 15, and 16, did not contain documentation of an orientation.

rule: R9-10-314. Physical Health Services A. An administrator shall ensure that: 2. Nursing services are provided c. To meet the needs of a patient based on the patient's acuity; and

evidence: Based on a review of medical records, observation and staff interview, it was determined the facility failed to document care provided to a patient who reported symptoms of chest pain. This deficient practice poses the potential risk of patient harm or death if a patient reports life threatening symptoms and no care is provided. .

findings: A review of the medical record of Patient #6 revealed "...Patient reports chest pain radiating down left arm. Reported to nursing..." documented by a Behavioral Health Technician on February 16, 2023. Documentation that the patient was seen by nursing for these symptoms was requested. None was provided. Medical record for Patient #6 revealed the patient was next seen on February 27, 2023. Employee #5 confirmed in an interview on December 19, 2023, that no documentation that an appropriate medical professional evaluated the patient's symptoms could be provided.

rule: R9-10-115. Behavioral Health Paraprofessionals; Behavioral Health Technicians_x000D_ 4. A behavioral health technician receives clinical oversight at least once during each two week period, if the behavioral health technician provides services related to patient care at the health care institution during the two week period;_x000D_ _x000D_ _x000D_ _x000D_ _x000D_

evidence: Based on review of policy and procedure, facility documents, and interview, the Department determined the administrator failed to document that clinical oversight was provided to (5) of (5) behavioral health technicians (BHT) reviewed at least once each two-week period if the BHT provides services related to patient care at the health care institution during the two-week period. This deficient practice poses a potential risk that staff are not adequately supervised by behavioral health professionals (BHP) to provide services to patients.

findings: Documentation for clinical oversight for September, October and November 2023, was requested for Employees #21, 22, 23, 24, & 25. The following documentation was missing: Employee #21: No documentation was provided for clinical oversight for one of three sessions in October and one of two sessions in November. Employee #22: No documentation was provided for clinical oversight for one of three sessions in October and one of two sessions in November. Employee #23 No documentation was provided for clinical oversight for one of two sessions in November. Employee #24 No documentation was provided for clinical oversight for one of two sessions in September. Employee #25 No documentation was provided for clinical oversight for one of two sessions in September. Employee #2 confirmed in an interview on December 19, 2023, that the above missing clincial oversight documentation was not available to review.


facility_name: MINGUS MOUNTAIN ESTATE RESIDENTIAL CENTER, INC

summary: Other - 11/12/2024

raw_content: No deficiencies were found during the on-site inspection to increase the occupancy from seven to eight, conducted on November 12, 2024.


summary: Complaint - 10/29/2024

raw_content: An on-site investigation of complaint AZ00218019 was conducted on October 29, 2024 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 record review and interview, the administrator failed to ensure a resident did not have access to any materials, furnishings, or equipment or participate in any activity or treatment to present a threat to the resident's health or safety based on the resident's personal history. The deficient practice posed a risk as R1 had access to a razor l while admitted into a behavioral health residential facility in contradiction with R1 ' s personal history.

findings: 1. A review of R1 ' s medical record revealed an incident report dated on October 17, 2024. The report indicated R1 attempted to self-harm while in the shower using a razor R1 requested from staff. 2. A review of R1 ' s medical record revealed an incident report dated on October 26, 2024. The report indicated R1 requested a razor when R1 was showering and was provided a razor by staff. The report indicated R1 used the razor to self-harm while in the shower and reported the incident to 3.The incident was documented by E2. The report indicated E2 and E3 provided first aid before E2 and E3 were advised by the facility ' s registered nurse (RN) to call 911. 3. A review of R1 ' s medical record revealed a behavioral health assessment dated on 2024. The assessment stated R1 was "high risk" for "self-harm/suicide." 4. In an interview, E1 confirmed the razor was provided to R1 by staff. E1 acknowledged R1 had access to a razor that presented a threat to R1's health or safety based on R1 ' s personal history.


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

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


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

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


facility_name: INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT

summary: Complaint - 3/10/2026

raw_content: No deficiencies were found during the on-site investigation of complaint 00161531 conducted on March 10, 2026.


summary: Complaint - 1/30/2026

raw_content: No deficiencies were found during the on-site  investigation of complaint 00157378 conducted on January 30, 2026:


summary: Complaint - 10/23/2025

raw_content: The following deficiencies were found during the on-site investigation of complaints 00147643, 00147795, 00148293, 00148462, and 00148574 conducted on October 23, 2025:

rule: R9-10-113.A.1-2. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

evidence: Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by or providing volunteer services for the health care institution. The deficient practice posed a potential TB exposure risk to residents.

findings: 1. A review of E4's personnel record revealed TB signs and symptoms training dated October 15, 2024. However, documentation of current TB signs and symptoms training was not available for review. 2. In an interview, E1 reported E4 did not complete the yearly training.

rule: R9-10-703.K.8.a-c. Administration K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a resident’s absence that includes the: a. Name of a resident absent without authorization, b. Name of the individual to whom the report required in subsection (K)(6) was submitted, and c. Date of the report; and

evidence: Based on documentation review, record review, and interview, the administrator failed to maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence, which included the name of the resident absent without authorization, the individual to whom the report was submitted, and the date of the report. The deficient practice posed a risk to the health and safety of residents if staff did not maintain a written log of unauthorized absences to review and take corrective action.

findings: 1. A review of R2's medical record revealed an incident report dated October 20, 2025. The report stated, "... Date of Incident: 10/18/2025; Report Created: 10/20/2025... On Saturday, October 18, 2025, at ICHD AIC Sunrise, member and a peer began screaming while throwing chairs in the dining room after staff attempted to instruct [R2] on how to have more appropriate conversations with [R2's] peers. More staff entered the dining room to intervene, and member and peer ran outside. Staff followed. Staff returned shortly with shoes belonging to member and reported to the other staff that member and peer had climbed over the gate. Two staff immediately pursued member in ICHD vehicle. Once close enough, one staff exited the vehicle and followed on foot and maintained a line of sight. After ~20 minutes, staff was able to convince member and peer to return to AIC. Once in the ICHD vehicle, staff assessed the member and peer for injuries. Member had a bruised, bleeding knee. Member also informed staff that [R2's] head had bounced off the concrete when [R2] fell on the ground after climbing over the driveway gate. Member informed staff that [R2's] head was throbbing. Once inside, staff attempted to assist member with first aid. Member refused. At ~8:45 PM. TFD arrived on site to assist member after [R2] refused to be transported by male staff. Member refused to be transported by male TFD staff. At ~9:45 PM, female staff arrived from another ICHD site to transport member to [emergency room] t to be assessed for a possible head injury... Once at [emergency room], member informed [emergency room] staff that [R2's] head did not actually bounce off the concrete when [R2] fell on the ground after climbing over the driveway gate. The wound to [R2's] knee was washed, steri-strips were applied, and [R2] received a prescription for 500 mg acetaminophen tablets to be taken every 6 hours as needed for pain. The prescription was sent to [pharmacy]. Member discharged from [emergency room]... On-call initially called/notified at ~7:56 PM and updated throughout. Guardian called/notified at ~8:10 PM. 911 initially called/notified of member AWOL at ~8:14 PM. CPIH Desert Mountain RN called for advisement on injuries at ~8:22 PM. 911 called/notified of needing assistance with transportation to ED at ~ 8:37 PM..." 2. A review of facility documentation revealed no documentation of a written log of unauthorized absences. 3. In an interview, E1 reported that there was no AWOL log available for review.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel that included documentation of the individuals completed in-service education as required by policies and procedures. The deficient practice posed a risk to the health and safety of residents if staff were unable to safely assist during sudden, intense, or out-of-control behavior.

findings: 1. A review of facility documentation revealed a policy titled "Permissible Behavior Management Techniques." The policy stated, "... 3. If an individual engages in a sudden, intense, or out-of-control aggressive or destructive behavior, which is endangering the health or safety of the individual or another individual, the following shall be done: a. Staff will initially utilize preventive interventions which may include, but are not limited to, the following techniques; b. Calm request to cease behavior; c. Calm redirection to a more desirable (to the community) task or activity; d. Removing other individuals from the immediate areas; e. Removing any potentially dangerous objects from the immediate area; f. Utilization of a novel, distracting, and interrupting stimuli; g. Defensive positioning; h. Calling for assistance; 4. Only when the above techniques have been proven to be ineffective, should staff utilize some form of emergency safety response. Staff should use the least amount of intervention to safely manage the individuals "out-of-control" behavior; 5. The emergency safety response utilized should be only those taught in the approved curriculum crisis prevention intervention (CPI), Safety Care or Prevention and Support and used only: a. By staff with training in the specific techniques and who have been trained or recertified within the past year... B. Approved Behavior Management Curriculum... 2. All staff members using non-violent crisis prevention intervention (CPI) or safety care techniques are certified in the use of those techniques by a certified instructor and are recertified in CPI or safety care techniques annually... C. Seclusion and Restraint: Intermountain Centers for Human Development and its affiliate organizations do not employ the practice of seclusion or restraint in an outpatient or residential group or foster home setting. Higher levels of care, such as inpatient subsacute setting, seclusion or restraint may be provided, only if licensed to do so, and in accordance with policy; D. Reporting: 1. Within 24 hours after an emergency safety response is used for a member, the following information is entered into the member's medical record and reviewed with the staff's administrator or clinical director: a. The date and time the emergency safety response was used; b. The name of each staff member who used an emergency safety response; c. The specific emergency safety response used; d. The staff member or resident behavior, event, or environment factor that caused the need for the emergency safety response; and e. Any injury that resulted from the emergency safety response..." 2. A review of E4's personnel record revealed safety care training dated October 22, 2024. However, documentation of training in non-violent crisis prevention or safety care techniques was not completed annually as required by the facility policies. 3. In an interview, E1 reported E4 had not completed the yearly training yet.

rule: R9-10-716.A.7.b. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or 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 does not 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. The deficient practice posed a risk as the health and safety of residents with a history of physical aggression was elevated and compromised.

findings: 1. A review of R2's medical record revealed an incident report dated October 20, 2025. The report stated, "... Description of the Incident: While playing basketball, member and a peer began to argue about the handling of the ball. Member and peer began to posture towards each other and began making verbal threats to each other. Member and peer then attempted to physically fight, but staff intervened, with staff attempting to hold and separate the two. Another peer approached the member and told [R2] that [R2] needed to 'stop' and grabbed member by the shoulder to steer [R2] away from the peer [R2] was attempting to hit. Member then turned [R2's] attention to the second peer and began to hit that peer. The two began to punch, kick, and grab each other. Member and peer had thrown each other to the ground and staff was unable to get ahold of either member to separate the two. Since physical separation was not successful, staff attempted to redirect the two verbally. Member and peer continued to hit each other and pull each other by the hair. Both member and peer eventually let go of each other and were separated. Member could not get up from the ground, claiming [R4] thinks [R4's] leg is broken since peer 'stomped' on [R4's] knee. Police and EMS arrived on scene to assess member and decided that member needed to be taken to [hospital] to be medically examined/cleared. Member was transported to [hospital] via ambulance and X-rays and CT scans were ordered. Member is currently at [hospital]. 911 was called at 18:11. Supervisor, on-call, and guardian were contacted around 18:30.... Witnesses: [E6]..." 2. A review of R2's medical record revealed a behavioral health assessment. The assessment stated, "... Traumas, Risks, Alerts: History of Non-Suicidal/Self-Injurious Behavior: Yes; If Yes, Please Elaborate: member reported that [R2] used to cut self but does not anymore... Does Individual Have Current or Past Difficulties with Anger?: Yes; Has Individual Ever Been Destructive to Property?: Yes; If Yes, Most Recent Date: 08/13/2025; Has Individual Ever Been Violent Towards Persons?: Yes; If Yes, Most Recent Date: 09/03/2024; Who Was Violence Directed Toward?: Member's aunt; Did Violence Ever Result in Injury?: No; Was the Individual Under the Influence of Drugs or Alcohol?: Member confirmed that the violence was toward [R2's] aunt, but declined to offer further explanations... Did the Individual Present a Risk to Themselves?: Yes... Assessed Need: It is the recommendation of this writer that member would benefit from receiving clinical assessment/observation and functional behavioral assessment at AIC. Member will have medication management, behavior coaching, individual and family counseling, and 24/7 monitoring..." 3. A review of R3's medical record revealed a behavioral health assessment. The assessment stated, "... Traumas, Risks, Alerts: History of Non-Suicidal Injurious Behavior: Yes; If Yes, Please Elaborate: Member hits [R3] and head bangs [R3's] head on floor or wall. Member also reported pinching self... Does Individual Have Current or Past Difficulties with Anger?: Yes; Has Individual Ever Been Destructive to Property?: Yes; If Yes, Most Recent Date: 07/31/2025; Has Individual Ever Been Violent Toward Persons?: Yes; If Yes, Most Recent Date: 09/24/2025; Who Was Violence Directed Toward?: Hospital staff; Did Violence Ever Result in Injury?: No; Was the Individual Under the Influence of Drugs or Alcohol?: None reported... Do You Engage in Any Sexual Behaviors?: Yes; If Yes, Explain: Member inappropriately exposes self to others and touches others inappropriately... Did the Individual Present a Risk to Themselves?: Yes... Assessed Need: It is the recommendation of this writer that member would benefit from receiving clinical assessment/observation and functional behavioral assessment at AIC... Level of Care/Indicated Service Recommendations: BHRF level of care. Member will have medication management, behavior coaching, individual and family counseling, and 24/7 monitoring..." 4. A review of R4's medical record revealed a behavioral health assessment. The assessment stated, "... Traumas, Risks, Alerts... History of Non-Suicidal Injurious Behavior: Yes; If Yes, Please Elaborate: member engaged in self-harm behaviors such as cutting arm superficially with knife but stated [R4] had done it two years ago. This contradicts members earlier report that [R4] had done it 3 weeks ago... Does Individual Have Current or Past Difficulties with Anger?: Yes; If Yes, Please Elaborate: Member has history of property damage and aggression towards guardian; Has Individual Ever Been Destructive to Property?: Yes; If Yes, Most Recent Date: 9/9/25; Has Individual Ever Been Violent Towards Persons?: Yes; Violent Date: 8/14/25; Who Was Violence Directed Towards?: Guardian; Did Violence Ever Result in Injury and/or Involve the Use of a Weapon?: No; Was the Individual Under the Influence of Drugs or Alcohol at the Time?: No; Did the Individual Present a Risk to Themselves and/or Others in the Past?: Yes; Does the Individual Currently Present a Risk to Themselves and/or Others?: No... Assessed Need: It is the recommendation of this writer that member would benefit from receiving 30-day clinical assessment and functional behavioral analysis at AIC and obtain treatment. Member will have medication management, behavior coaching, individual and family counseling, and 24/7 monitoring... Level of Care/Indicated Service Recommendations: BHRF AIC..." 5. In an interview, E1 reported all residents have behavioral issues that are screened when admitted. E1 also reported residents were appropriate to receive services at AIC and are constantly monitored to ensure the health and safety of other residents.

rule: R9-10-716.E.2.b. Behavioral Health Services E. An administrator shall ensure that: 2. Within 24 hours after an emergency safety response is used for a resident, the following information is entered into the resident medical record: b. The name of each personnel member who used an emergency safety response;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure the name of each personnel member who used an emergency safety response was documented in the resident's medical record. The deficient practice posed a risk to the health and safety of residents if staff did not document the individual who implemented the emergency safety response and their ability to use the training.

findings: 1. A review of facility documentation revealed a policy titled "Permissible Behavior Management Techniques." The policy stated, "... 3. If an individual engages in a sudden, intense, or out-of-control aggressive or destructive behavior, which is endangering the health or safety of the individual or another individual, the following shall be done: a. Staff will initially utilize preventive interventions which may include, but are not limited to, the following techniques; b. Calm request to cease behavior; c. Calm redirection to a more desirable (to the community) task or activity; d. Removing other individuals from the immediate areas; e. Removing any potentially dangerous objects from the immediate area; f. Utilization of a novel, distracting, and interrupting stimuli; g. Defensive positioning; h. Calling for assistance; 4. Only when the above techniques have been proven to be ineffective, should staff utilize some form of emergency safety response. Staff should use the least amount of intervention to safely manage the individuals "out-of-control" behavior; 5. The emergency safety response utilized should be only those taught in the approved curriculum crisis prevention intervention (CPI), Safety Care or Prevention and Support and used only: a. By staff with training in the specific techniques and who have been trained or recertified within the past year... B. Approved Behavior Management Curriculum... 2. All staff members using non-violent crisis prevention intervention (CPI) or safety care techniques are certified in the use of those techniques by a certified instructor and are recertified in CPI or safety care techniques annually... C. Seclusion and Restraint: Intermountain Centers for Human Development and its affiliate organizations do not employ the practice of seclusion or restraint in an outpatient or residential group or foster home setting. Higher levels of care, such as inpatient subsacute setting, seclusion or restraint may be provided, only if licensed to do so, and in accordance with policy; D. Reporting: 1. Within 24 hours after an emergency safety response is used for a member, the following information is entered into the member's medical record and reviewed with the staff's administrator or clinical director: a. The date and time the emergency safety response was used; b. The name of each staff member who used an emergency safety response; c. The specific emergency safety response used; d. The staff member or resident behavior, event, or environment factor that caused the need for the emergency safety response; and e. Any injury that resulted from the emergency safety response..." 2. A review of R2's medical record revealed an incident report dated October 19, 2025. The report stated, "... On 10/19/25 at approximately 9:02 AM, the member engaged in verbal aggression toward [R2's]... roommate in the kitchen common area. The member made verbal threats, indicating potential physical aggression. Three staff intervened; one staff transitioned the peer outside to increase safety, while the remaining staff implemented Safety-Care verbal de-escalation strategies with the member. Despite intervention, the members behavior escalated from verbal to physical aggression, including threats to punch the peer and attempts to move toward [R4]. When the member began attempting to throw punches and push past staff to reach the peer, staff implemented a Safety-Care physical hold for approximately 30 seconds. The hold was released once the member regained some control. No physical contact occurred between the member and the peer. Following release, the member exhibited continued agitation and attempted property destruction by punching walls. No damage occurred, and no aggression toward others followed. Staff maintained verbal de-escalation until the member became calm approximately 9:17 AM..." However, the name of the individual who used an emergency safety response was not documented in the incident report. 3. In an interview, E1 reported E6 was the staff member who used an emergency safety response. 4. In an interview, E1 reported the name of the personnel member using the emergency safety response was not documented in the incident report.

rule: R9-10-718.C.6.a. Medication Services C. If a behavioral health residential facility provides assistance in the self-administration of medication, an administrator shall ensure that: 6. Assistance in the self-administration of medication provided to a resident: a. Is in compliance with an order, and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order. The deficient practice posed a risk to the health and safety of residents if the required medication for treatment was not received.

findings: 1. A review of R1's medical record revealed the following orders: Triamcinolon 0.1% Cream, apply a thin layer topically twice a day to the affected area; Prazosin HCL 2 mg Cap, take 1 capsule by mouth every night at bedtime (stop if you feel faint or dizzy); Risperidone 3 mg Tab, take 1 tablet by mouth every night at bedtime; Risperidone 2 mg Tab, take 1 tablet by mouth every morning; and Guanfacine 1 mg ER Tab, take 1 tablet by mouth every night at bedtime. 2. A review of R1's medical record revealed a discharge summary from a previous facility dated September 17, 2025. The summary stated, "... Discharge Medication: RisperiDONE Oral Tablet 1 mg (RisperDAL), 1 tab oral HS, all 15 tab; GuanFACINE HCL Oral Tablet 1 mg(TENEX), 0.5 tab oral daily once, all 15 tab; Prazosin HCL Oral Capsule 2 mg (Minipress), 1 cap oral HS, all 15 cap; GuanFACINE Oral Tablet Extended Release 24 Hour 3 mg (INTUNIV), 1 tab oral daily once, all 15 tab..." 3. A review of R1's medical record revealed a September 2025 medication administration record (MAR). The MAR revealed the following medications were not documented as taken on the following dates: - Risperidone 1 mg tab on September 19, 2025. - Risperidone 3 mg tab on September 17, 2025; - Risperidone 2 mg tab on September 18, 2025; - Guanfacine 1 mg ER Tab on September 18, 2025, September 19, 2025; - Guanfacine 3 mg ER Tab on September 19, 2025; and - Prazosin HCL 2 mg Cap on September 19, 2025. 4. A review of R1's medical record revealed an October 2025 MAR. The MAR revealed the following medications were not documented as taken on the following dates: - Triamcinolon 0.1% Cream from October 2, 2025, to October 23, 2025; - Guanfacine 3 mg ER Tab from October 4, 2025, to October 10, 2025; and - Risperidone 1 mg Tab on October 4, 2025, October 5, 2025, October 6, 2025, October 8, 2025, and October 9, 2025. 5. In an interview, E1 reported issues obtaining medications when R1 was transferred to the facility.


summary: Complaint;Compliance (Annual) - 9/15/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00143210 and AZ00144691 conducted on September 15, 2025:

inspection_type: Complaint;Compliance (Annual)

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

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

findings: 1. A review of Department documentation revealed BH1618 notified the Department of R1's self-injury on September 11, 2025. 2. In a joint interview, E4 and E9 reported R1's self-injury occurred on September 5, 2025. 3. A review of facility documentation revealed a screenshot of BH1618's written notification of R1's self-injury to the Department via the portal on September 11, 2025. 3. In a joint interview, the findings were discussed with E4 and E9. E4 and E9 acknowledged the facility did not notify the Department of R1's self-injury within two working days due to technological issues and did not become unaware of the incident until September 11, 2025.

evidence: Based on a record review, documentation review, and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was provided in compliance with an order for one of four sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper assistance in the self-administration of medication. and and the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of R3's medical record revealed a medication order dated June 5, 2025. The order stated, "...Continue Risperdal 1mg at 7am and 7pm-for mood/behaviors..." 2. A review of facility policies and procedures revealed a policy (last revised May 2, 2023) titled "Assistance in the Self-Administration of Medication." The policy stated, "It is the policy of Intermountain Centers for Human Development, Inc. (Intermountain Centers) and its business affiliates to assist residents/members in the appropriate self-administration of medication." 3. A review of R3's medical record revealed a medication administration record dated September 15, 2025. The record did not indicate whether R3 received assistance with the self-administration of Risperdal 1 mg at 7:00 a.m. and 7:00 p.m. 4. In an interview, E10 reported R3 did not receive assistance with the self-administration of the aforementioned Risperdal on September 15, 2025, as there was medication to provide to R1. 5. In an exit interview, the findings were discussed with E4 and E9, and no additional statements or documentation were provided. This is a repeat violation from the complaint investigation conducted on January 29, 2025.

rule: R9-10-720.B.4. 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: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

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

findings: 1. A review of facility documentation revealed no disaster drills. 2. In an interview, E4 reported disaster drills were conducted at least every three months on each shift. However, no disaster drill documentation was provided. 3. In an exit interview, the findings were discussed with E4 and E9. E4 reported being unable to locate the disaster drill documentation.

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

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

findings: 1. A review of facility documentation revealed no evacuation drills. 2. In an interview, E4 reported evacuation drills were conducted at least once every six months on each shift. However, no documentation of the evacuation drills was provided. 3. In an exit interview, the findings were discussed with E4 and E9. E4 reported being unable to locate the documentation of the evacuation drills.


summary: Complaint - 8/21/2025

raw_content: No deficiencies were found during the on-site investigation of complaint 00139027 conducted on August 21, 2025.


summary: Complaint - 8/1/2025

raw_content: The following deficiency was found during the on-site  investigation of complaint 00138133 conducted on August 1, 2025:

rule: R9-10-703.C.2.f. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a resident that: f. Cover dispensing medication, administering medication, assistance in the self-administration of medication, and disposing of medication, including provisions for inventory control and preventing diversion of controlled substances;

evidence: Based on documentation review and interview, the administrator failed to implement policies and procedures for behavioral health services to protect the health and safety of a resident to cover assistance in the self-administration of medication, for one of two residents sampled. The deficient practice posed a health and safety risk if R1 experienced a change of condition due to improper assistance in the self-administration of medication.

findings: 1. A review of facility documentation revealed an incident report (dated July 2025) regarding R1. The incident report stated, "7:30 PM, [R1] self-administered [R1's] evening medication, [R1] was given [R1's] bottle of Guanfacine 1mg tablets...[R1] poured what appeared to be 2 extra pills in [R1's] hand and immediately takes them. [R1] ignored [E7's] attempts to intervene, and swallowed the pills. Shortly after, [R1] approached [E2] requesting a [one-on-one] conversation, [R1] disclosed, 'I took two extra pills. I wanted to attempt tonight, I don't want to be in pain. I want to die. I don't want to be here anymore.' At that moment, [R1] began crying and coughing. [E2] asked if [R1] was feeling okay and if [R1] had current thoughts of self-harm. [R1] stated, 'I want to be in heaven with my dog. I don't want to wake up tomorrow. I want to die.'" The on-call supervisor was notified, Poison Control was contacted and advised that "the member required immediate transport to Tucson Medical Center (TMC)...8:09 PM 911 was called...Emergency Services opted to dispatch both Crisis Mobile and an ambulance...8:30 PM Tucson Police Department arrived on-site...8:55 PM Ambulance arrived and determined that [R1] required transport to TMC...9:12 PM [R1] was transported to TMC by ambulance. [R1] was admitted at 9:45 PM...Afterwards, [R1] was recommended to a higher level of care at Sonora Hospital." 2. A review of facility documentation revealed a policy and procedure (last revised May 2, 2023), titled "Assistance in the Self-Administration of Medication." The policy stated, "...Staff will verify medication orders, match the prescription label, and the medication administration record (MAR)...Staff will utilize the 7 R's (right person, right medication, right dose, right time, right route, right documentation, right to refuse) for each medication...Staff will ask the resident/member to confirm the information is accurate on the prescription bottle/DISPILL pack, including resident/member name, medication, dose, route, frequency...Staff will provide the resident/member with access to one medication container/DISPILL pack at a time...Residents/members will self-administer [sic the medication, then swish and swallow....Staff will verify that medication was taken...'' 3. In an exit interview, E1 acknowledged the facility's assistance in the self-administration of medication policy was not implemented, as R1 took the wrong dosage of a medication.


summary: Complaint - 4/22/2025

raw_content: An on-site investigation of complaint 00126222 was conducted on April 22, 2025, and no deficiencies were cited.


summary: Complaint - 3/26/2025

raw_content: An on-site investigation of complaints 00123825 and 00123973 was conducted on March 26, 2025, and no deficiencies were cited.


summary: Complaint - 3/20/2025

raw_content: An on-site investigation of complaint 00122963 was conducted on March 20, 2025 and no deficiencies were cited.


summary: Complaint - 2/26/2025

raw_content: An on-site investigation of complaints 00116386 and 00116389 were conducted on February 26, 2025 and the following deficiencies were cited:

rule: R9-10-721.A.14. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 14. Poisonous or toxic materials stored by the behavioral health residential facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

evidence: Based on observation and interview, the administrator failed to ensure poisonous or toxic materials stored by the behavioral health residential facility were stored in labeled containers in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.

findings: 1. The Compliance Officer observed the following in an unlocked cabinet beneath the kitchen sink: An unlabeled bottle containing blue liquid. The unlabeled bottle did contain a warning that stated "Keep out of reach of children." The bottle had a list of potential cleaning agents to check off what the contents of the bottle may contain. However, no option was selected. 2. In an interview, E1 acknowledged an unlabeled toxic material was in an unlocked cabinet beneath the kitchen sink and accessible to residents. E1 reported the unlabeled bottle contained glass cleaner. 3. In an exit interview, the findings were discussed with E1, E2, E3 and E4 and no additional statements were provided.

rule: R9-10-722.E.2.f.i. Physical Plant Standards E. If a swimming pool is located on the premises, an administrator shall ensure that: 2. The swimming pool is enclosed by a wall or fence that: f. Has a self-closing, self-latching gate that: i. Opens away from the swimming pool,

evidence: Based on observation and interview, the administrator failed to ensure the swimming pool located on the premises, enclosed by a fence, had a self-closing, self-latching gate that opened away from the swimming pool.

findings: 1. The Compliance Officer observed a swimming pool on the premises, enclosed by a fence. The pool fence contained two gates. The pool gate to the left was locked. The gate to the right of the pool contained a self-closing latch, however, the gate entered into the pool area. 2. In an interview, E1 acknowledged one gate did not open away from the swimming pool. 3. In an exit interview, the findings were discussed with E1, E2, E3 and E4 and no additional statements were provided.

rule: R9-10-722.E.2.f.iii. Physical Plant Standards E. If a swimming pool is located on the premises, an administrator shall ensure that: 2. The swimming pool is enclosed by a wall or fence that: f. Has a self-closing, self-latching gate that: iii. Is locked when the swimming pool is not in use; and

evidence: Based on observation and interview, the Administrator failed to ensure the swimming pool, enclosed by a fence, had a self-closing, self-latching gate that was locked when the swimming pool was not in use.

findings: 1. The Compliance Officer observed a swimming pool on the premises, enclosed by a fence. The pool fence contained two gates. The gate to the right of the pool contained a self-closing latch, however, the gate entered into the pool area and was not locked. The swimming pool was not currently in use. 2. In an interview, E1 acknowledged one gate was not locked. 3. In an exit interview, the findings were discussed with E1, E2, E3 and E4 and no additional statements were provided.


summary: Complaint - 1/29/2025

raw_content: An on-site investigation of complaints AZ00222456 and AZ00222742 was conducted on January 29, 2025 and the following deficiencies were cited :

evidence: Based on documentation review, record review, observation, and interview, an administrator failed to ensure a resident did not have access to any materials, furnishings, or equipment presenting a threat to the resident's health or safety based on the resident's documented diagnosis. The deficient practiced posed a risk to the physical health and safety of a resident. 1. A review of facility documentation revealed an incident report regarding R1. The incident reported stated, "@ 830AM [R1] told staff [R1] wasn't feeling good and wanted to go to the CRC. Staff called crisis mobile out to evaluate [R1]. 10:20AM After evaluation, the crisis team felt [R1] didn't fit the criteria for the CRC based on [R1] reason of not wanting to be at the [facility]. 10:28AM [R1] became upset, screamed, threatened, did property damage, and hit the crisis worker with a chair. Stated: "I don't want to be here!" Staff removed the audience, gave expectations to be safe, and brought [R1] outside for a break. @10:35AM Police were called. 10:36AM [R1] was unresponsive to staff's help strategy, started throwing rocks, hit staff several times and staff instructed the crisis team to move their vehicle. [R1] threw rocks at the crisis team. @11AM [R1] threw rocks at the Rincon window, breaking them, staff continued to give expectations to be safe. @11:05 [R1] picked up glass and [R1] put it to [R1's] arm, staff went after the piece of glass, and [R1] ran while cutting [R1]." 2. A review of R1's medical record revealed R1 had a recent history of suicidal ideation and self harm. However, R1 reportedly did not have serious indication of suicidal ideation or risk of self harm upon admittance to the facility. 3. The Compliance Officer observed maintenance staff replacing the windows R1 broke on-site. Maintenance staff showed the Compliance Officer photos of the previously shattered windows. The Compliance Officer observed every other window at the facility was made of plastic. 4. In an exit interview, E1 reported maintenance staff replaced the windows with new glass windows. However, R1 reported maintenance staff would put up metal bars over the windows to prevent the windows from shattering again.

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

evidence: Based on record review and interview, the administrator failed to ensure assistance in the self-administration of medication provided to a resident was in compliance with an order, for two of three residents sampled who received assistance in the self-administration of medication. The deficient practice posed a risk if a resident experienced a change in condition due to improper assistance in the self-administration of medication.

findings: 1. A review of R1's medication administration record (MAR) revealed R1 received assistance in the self administration of medication for the following medications from R1's date of admission (January 2025) to date of discharge (January 2025): - Oxcarbazepine 300 mg tablet, take 1 tablet by oral route3 times every day; - Lurasidone 120 mg tablet, take 1 tablet by oral route at 6pm for mood; - Melatonin 3 mg tablet; and - Escitalopram 20 mg tablet, take 1 tablet by oral route every day. 2. A review of R1's medical record revealed R1 did not have a medication order for any of R1's medications. 3. A review of R2's MAR revealed R2 received assistance in the self administration of medication for the following medications from R2's date of admission (November 2024) to date of discharge (December 2024): - Dextroamphetamine-amphetamine 5 mg tablet, take 1/2 tablet by oral route daily after lunch for ADHD; - Sertraline 100 mg tablet, take 1 tablet by oral route daily for anxiety and depression; and - Aripiprazole 10 mg tablet, take 1 tablet by oral route daily in the morning for mood. 4. A review of R2's medical record revealed R2 did not have a current medication order for R2's medications. 5. In an exit interview, the Compliance Officer informed E1, E2, and E3 of the findings. E1, E2, and E3 did not provide any additional information. 4. A review of R2's medical record revealed R2 did not have a current medication order for R2's medications. 5. In an exit interview, the Compliance Officer informed E1, E2, and E3 of the findings. E1, E2, and E3 did not provide any additional information.