summary: Complaint - 12/30/2025

raw_content: An on-site investigation of complaint 00154509 was conducted on December 30, 2025, and the following deficiencies were cited:

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

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure that sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as staff lacked the implementation of the necessary skills and knowledge to ensure the health and safety of residents under the age of 18, leading to an incident.

findings: 1. A review of R1's medical record revealed an incident report dated December 24, 2025, written by E4. The report stated "....There were reports during the evening that client was going to AWOL. Staff kept a close eye on the client and spoke to client about how stupid it is to AWOL. Client stated [R1] agreed and understood what I was telling [R1]. Client begged to go outside after the families left. Staff told [R1] no. There was music being played in the backyard. Staff errantly allowed client to go back to listen. Staff checking on [R1] several times when [R1] was outside. I went outside and took the trash out right after checking that the client was still here. I was gone maybe 2 minutes and [R1] client AWOL'd, going over the wall in the backyard. House...." The incident reported R1 and R2 left the facility together. 2. A review of E4's personnel record revealed E4 was hired as a behavioral health technician. E4's personnel file reflected that providing continuous protective oversight to the residents was a job duty. Although E4 had the documentation of sufficient skills and knowledge to provide continuous protective oversight to the residents, the skills and knowledge were not implemented or sufficient at the time of the incident on December 24, 2025. 3. In an interview, E1 and E6 acknowledged the incident report revealed E4 did not provide R1 and R2 continuous protective oversight as required in E4's job duties, leading to an incident that did not ensure the health and safety of R1 and R2.

rule: R9-10-709.G.1-2. Discharge G. An administrator shall ensure that a discharge summary for a resident: 1. Is entered into the resident’s medical record within 10 working days after a resident’s discharge; and 2. Includes: a. The following information authenticated by a medical practitioner or behavioral health professional: i. The resident’s presenting issue and other physical health and behavioral health issues identified in the resident’s treatment plan; ii. A summary of the treatment provided to the resident; iii. The resident’s progress in meeting treatment goals, including treatment goals that were and were not achieved; and iv. The name, dosage, and frequency of each medication ordered for the resident by a medical practitioner at the behavioral health residential facility at the time of the resident’s discharge; and b. A description of the disposition of the resident’s possessions, funds, or medications brought to the behavioral health residential facility by the resident.

evidence: Based on record review and interview, the administrator failed to ensure a discharge summary for a resident was entered into the resident’s medical record within 10 working days after a resident’s discharge and included the following information authenticated by a medical practitioner or behavioral health professional; the resident’s presenting issue and other physical health and behavioral health issues identified in the resident’s treatment plan, a summary of the treatment provided to the resident, the resident’s progress in meeting treatment goals, including treatment goals that were and were not achieved, the name, dosage, and frequency of each medication ordered for the resident by a medical practitioner at the behavioral health residential facility at the time of the resident’s discharge, and a description of the disposition of the resident’s possessions. The deficient practice poses a risk as the clinical provider did not authenticate the discharge.

findings: 1. A review of R1's medical record revealed a discharge summary completed by E6. The discharge summary did not include authentication of the discharge by a medical practitioner or behavioral health professional. 2. In an interview, E6 reported E6 completed the discharge. E6 confirmed E6 was not a medical practitioner or behavioral health professional. E6 reported the discharge should have been reviewed and authenticated by the facility's behavioral health professional. E6 acknowledged R1's medical record did not include a discharge authenticated by a medical practitioner or behavioral health professional. 3. In an interview, E1 acknowledged R1's medical record did not include a discharge summary authenticated by a medical practitioner or behavioral health professional

rule: R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently receives: b. Continuous protective oversight;

evidence: Based on record review and interview, the administrator failed to ensure if a behavioral health residential facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as the lack of oversight led to an incident of individuals under 18 eloping from the facility.

findings: 1. A review of R1's and R2's medical records revealed that R1 and R2 were under the age of 18, requiring continuous protective oversight by the behavioral health residential facility. 2. A review of R1's medical record revealed an incident report dated December 24, 2025. The Incident report stated "....There were reports during the evening that client was going to AWOL. Staff kept a close eye on the client and spoke to client about how stupid it is to AWOL. Client stated [R1] agreed and understood what I was telling [R1]. Client begged to go outside after the families left. Staff told [R1] no. There was music being played in the backyard. Staff errantly allowed client to go back to listen. Staff checking on [R1] several times when [R1] was outside. I went outside and took the trash out right after checking that the client was still here. I was gone maybe 2 minutes and [R1] client AWOL'd, going over the wall in the backyard. House...." The incident reported R1 and R2 left the facility together. 3. In an interview, E1 and E6 acknowledged R1 and R2 were not provided continuous protective oversight on December 24, 2025, leading to R1 and R2 leaving the behavioral health facility without staff knowledge. This is a repeated deficiency from the complaint investigation conducted on October 7, 2025.


state: AZ

facility_name: HORIZON RECOVERY

summary: Complaint - 10/7/2025

raw_content: The following deficiencies were found during the on-site investigation of complaints 00144280 and 00146836 conducted on October 7, 2025:

inspection_type: Complaint

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

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was treated with dignity, respect and consideration. The deficient practice posed a risk as a resident was physically attacked by another resident.

findings: 1. A review of facility documentation revealed an incident report, dated in September 2025. The report stated "at 5:47 pm [R2] and [R1] got into a physical altercation in bedroom #5. The other residents tagged above [seven (7) residents listed) were banging on the door to the toilet trying to get [R2] to come out and fight. Those residents also barricaded the entry door to bedroom #5 so that staff could not get in. When [R2] came out of the bathroom, a fight ensued. The fight broke up and [R2] came downstairs and asked me [E5] for a bandaid for [R2's] left knee. It was bleeding slightly and I asked [R2] how it happened. [R2] told me [R2] bumped [R2's] knee on a bed. I was cooking dinner in the kitchen and the temp [E7] was taking a break. [E7] hadn't had one in about 3 hours. [R2] then went back upstairs and a second physical altercation occurred in bedroom #5 where [R2] was hit several times with rods that were broken out of the clothes hampers. [R2] also sustained blows to the face and back of the head. [R1] had also grabbed [R2] by the neck, leaving marks. The total time of the incidents was approximately 10 minutes. [E10] and [E5] performed an investigation and all of the residents were saying 'nothing happened.' All of this information came from [R2] during the conversation with [E10], the therapist on duty. [R2] then shared the information to me [E5] after the fact. [R2] said that the other residents made threats about not telling about it, so [R2] is fearful of further retribution from the other residents. End of IR." 2. A review of facility documentation revealed a daily staffing schedule, with dates ranging from September 29 - October 6, 2025. The schedule revealed E5 and E7 were scheduled to work 1:00 PM - 10:00 PM on September 30, 2025 and E10 was scheduled to work as a therapist 8:30 AM - 4:30 PM on September 30, 2025. 3. In an interview, R1 reported R1 was assigned to bedroom #5 and R2 was assigned to a different bedroom. R1 reported R2 oftentimes used R1's private bathroom inside bedroom #5, and R2 was disrespectful to R1 and other residents in the facility. R1 reported all seven residents were in R1's (bedroom #5) room and all personnel members were downstairs. R1 reported there were many occasions where the residents were left unsupervised. 4. In a joint exit interview with E1, E8 and E9, the findings were reviewed and no additional information or documentation was provided for review. E9 acknowledged residents' rights had been violated due to the resident fighting and misuse of the private bathroom in bedroom #5.

evidence: Based on documentation review and interview, the administrator failed to ensure a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as a resident was physically injured.

findings: 1. A review of facility documentation revealed an incident report, dated in September 2025. The report stated "at 5:47 pm [R2] and [R1] got into a physical altercation in bedroom #5. The other residents tagged above [seven (7) residents listed) were banging on the door to the toilet trying to get [R2] to come out and fight. Those residents also barricaded the entry door to bedroom #5 so that staff could not get in. When [R2] came out of the bathroom, a fight ensued. The fight broke up and [R2] came downstairs and asked me [E5] for a bandaid for [R2's] left knee. It was bleeding slightly and I asked [R2] how it happened. [R2] told me [R2] bumped [R2's] knee on a bed. I was cooking dinner in the kitchen and the temp [E7] was taking a break. [E7] hadn't had one in about 3 hours. [R2] then went back upstairs and a second physical altercation occurred in bedroom #5 where [R2] was hit several times with rods that were broken out of the clothes hampers. [R2] also sustained blows to the face and back of the head. [R1] had also grabbed [R2] by the neck, leaving marks. The total time of the incidents was approximately 10 minutes. [E10] and [E5] performed an investigation and all of the residents were saying 'nothing happened.' All of this information came from [R2] during the conversation with [E10], the therapist on duty. [R2] then shared the information to me [E5] after the fact. [R2] said that the other residents made threats about not telling about it, so [R2] is fearful of further retribution from the other residents. End of IR." 2. A review of facility documentation revealed a daily staffing schedule, with dates ranging from September 29 - October 6, 2025. The schedule revealed E5 and E7 were scheduled to work 1:00 PM - 10:00 PM on September 30, 2025 and E10 was scheduled to work as a therapist 8:30 AM - 4:30 PM on September 30, 2025. 3. In an interview, R1 reported R1 was assigned to bedroom #5 and R2 was assigned to a different bedroom. R1 reported R2 oftentimes used R1's private bathroom inside bedroom #5 and R2 was disrespectful to R1 and other residents in the facility. R1 reported all seven residents were in R1's (bedroom #5) room and all personnel members were downstairs. R1 reported there were many occasions where the residents were left unsupervised. 4. In a joint exit interview with E1, E8 and E9, E1 and E9 acknowledged the facility did not provide continuous protective oversight to ensure the safety of the residents during the above-mentioned incident. E9 reported the facility had been discussing staffing concerns to address a recent increase in incidents.


summary: Compliance (Initial) - 9/20/2024

raw_content: An off-site review of documentation for a change of ownership was completed on 09/20/2024.

inspection_type: Compliance (Initial)


facility_name: MS MIMI CARING HEART LLC

summary: Compliance (Annual) - 12/16/2025 - 12/17/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on December 16, 2025:

inspection_type: Compliance (Annual)

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

evidence: Based on documentation review, record review, and interview, the health care institution failed to administer an initial training and continued competency training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to residents if staff were unable to safely assist during a fall.

findings: 1. A review of facility documentation revealed a policy titled "Fall Prevention and Recovery." The policy stated, "... Fall prevention and recovery training is required upon hire and at least every 12 months thereafter..." 2. A review of E3's personnel record revealed no documentation of initial training in fall prevention and fall recovery was available for review. 3. In an interview, E1 and E2 reviewed the findings and reported E1 and E2 were unaware the contracted behavioral health professional also needed fall prevention and fall recovery training. E1 and E2 also reported the required training would be completed.

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 baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and documenting the individual's freedom from infectious TB. The deficient practice posed a potential TB exposure risk to residents.

findings: R9-10-113.B.1.c.(i-ii) B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have a history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. ii. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101; and Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution. 1. A review of E3's personnel record revealed a negative Mantoux skin test dated November 17, 2024. However, documentation of a second TB skin test or baseline screening, which consisted of assessing risks of prior exposure to infectious TB and determining if E3 had signs or symptoms of TB was not available for review. 2. A review of E3's personnel record revealed no documentation of training related to recognizing the signs and symptoms of TB. 3. In an interview, E1 and E2 reviewed the findings, and no additional documentation was provided 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 that included documentation of the individual's completed orientation. The deficient practice posed a risk to the health and safety of residents if staff were not oriented to the facility and its premises.

findings: 1. A review of facility documentation revealed a policy titled "Orientation and In-Service Education." The policy stated, "1. Each personnel member, employee, or student receives orientation before providing behavioral health services to a resident..." 2. A review of E3's personnel record revealed no documentation of completed orientation. 3. In an interview, E1 and E2 reviewed the findings and reported the orientation was completed but not documented. E1 and E2 also reported the documentation will be completed and placed in the personnel record.


summary: Initial Monitoring - 1/28/2025

raw_content: The following deficiencies were found during the on-site abbreviated follow-up inspection conducted on January 28, 2025:

inspection_type: Initial Monitoring

rule: A.R.S.§ 36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work.

evidence: Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), for two of five employees sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population.

findings: A.R.S. \'a7 36-411(A) states, "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 1. A review of facility documentation revealed a policy titled, "Employees and Volunteers Qualifications." The policy stated, "... 3. Fingerprinting requirements as specified in A.R.S. \'a7 36-411. As a condition of employment or volunteer services, the individual shall have valid fingerprint clearance card or shall apply for a fingerprint clearance card within 20 working days of employment or beginning volunteer services, as well shall present criminal history affidavit notarized before or on the starting day of employment..." 2. A review of E2's personnel record revealed a fingerprint clearance card expired in November 2024. However, documentation of a current fingerprint clearance card was not available for review. 3. A review of E5's personnel record revealed documentation of a fingerprint clearance card was not available for review. 4. In an interview, E2 reported E2 was unaware the fingerprint clearance card expired. 5. In an interview, E1 reported E5 has the fingerprint clearance card but cannot find the documentation. 6. In an exit interview, E1 and E2 reviewed the findings and not additional documentation was provided.

rule: A.R.S. § 36-411. Residential care institutions; nursing care institutions; home health agencies; fingerprinting requirements; exemptions; definitions C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card.

evidence: Based on record review and interview, the owner failed to ensure compliance with Arizona Revised Statutes A.R.S. § 36-411(C)(1) for one of five personnel records sampled. The deficient practice posed a safety risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection.

findings: A.R.S. § 36-411(C) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency." 1. A review of E5's personnel record revealed documentation of good faith efforts to contacts previous employers to obtain information or recommendation that may be relevant to a persons fitness to work in a residential care institution was not available for review. 2. In an exit interview, E1 reviewed the findings and no additional documentation was provided.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: d. The individual's license or certification, if the individual is required to be licensed or certified in this Article or policies and procedures;

evidence: Based on record review and interview, the administrator failed to ensure documentation of the individuals license or certification was maintained in a personnel record for one of five employees sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs at the facility.

findings: 1. A review of E2's personnel record revealed documentation of a professional license was not available for review. 2. In an interview, E1 and E2 reported E2 has a license but could not find the documentation. 3. In an exit interview, E1 and E2 reviewed the findings and no additional documentation was provided.

rule: R9-10-113. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1);

evidence: Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB. The deficient practice posed a potential TB exposure risk to residents.

findings: R9-10-113.B.1.c.(i-ii) B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. ii. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101; and Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution. 1. A review of E5's (hired September 2024) personnel record revealed a negative TB test dated January 24, 2023. However, documentation of evidence of freedom from infectious TB, as required in R9-10-113, and baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the individual had signs or symptoms of TB was not available for review. 2. In an interview, E1 reported E5 had the documentation but could not find the correct TB tests. 3. In an interview, E1 reviewed the findings and no additional documentation was provided.


summary: Compliance (Initial) - 9/18/2024 - 11/19/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on September 18, 2024 and the off-site documentation review completed on November 19, 2024.


facility_name: LWB WINTHROP HOUSE

summary: Initial Monitoring - 6/26/2025

raw_content: An on-site abbreviated inspection was conducted on June 26, 2025 and no deficiencies were cited.


summary: Compliance (Annual) - 6/26/2025

raw_content: The following deficiency was found during the on-site compliance inspection conducted on June 26, 2025.

rule: A.R.S. § 36-425.03.A. Children's behavioral health programs; personnel; fingerprinting requirements; exemptions; definitions A. Except as provided in subsections B, C and D of this section, children's behavioral health program personnel, including volunteers, shall submit the form prescribed in subsection E of this section to the employer and shall have a valid fingerprint clearance card issued pursuant to title 41, chapter 12, article 3.1 or, within seven working days after employment or beginning volunteer work, shall apply for a fingerprint clearance card.

evidence: Based on documentation review, record review and interview, the health care institution failed to ensure compliance with A.R.S. § 36-425.03.A. The deficient practice posed a risk if E1 was a danger to a vulnerable population.

findings: 1. A review of E1's personnel record revealed E1's fingerprint card "Expiration Date" was June 19, 2025. 2. A review of the psp.azdps.gov website (Arizona's Department of Public Safety (DPS) fingerprint verification website) revealed E1's "Level 1" fingerprint clearance card was listed as "Not Valid" and expired in June 2025. 3. A review of R1's, R2's, and R3's medical records revealed all residents were under 18 years of age. 4. In an interview, E1 reported being unaware E1's fingerprint clearance card was listed as "Not Valid" according to the DPS website. 5. In an exit interview, E1 reported E1 will start E1's fingerprint clearance application on the upcoming weekend, and no other statements were provided. 6. As of July 7, 2025, E1's did not have a valid fingerprint clearance card per the DPS fingerprint verification website


summary: Compliance (Initial) - 10/25/2024 - 11/7/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on October 25, 2024 and the off-site documentation review completed on November 7, 2024.


facility_name: DALIA HOMECARE VALENCIA

summary: Complaint - 1/14/2026

raw_content: The following deficiencies were found during the on-site investigation of complaint 00156088 conducted on January 14, 2026.

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 record review and interview, the administrator failed to provide written notification to the Department within two working days of a resident's accident requiring immediate intervention by an emergency medical services (EMS) provider. 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 R1’s medical record revealed a document titled "Incident Report" (dated January 10, 2026). The document stated “[R1] was being placed in an ambulance due to the seizure [R1] had moments before [R1] called out to [E1] before they closed the doors. [E1] looked in and [R1] was patting [R1's] pockets! [E1] asked [R1] what [R1] was looking for? [R1] said [R1] thought [R1] had a vape on [R1]. [E1] asked [R1] whose Vape was it and [R1] said it was [R1’s]. [R1] then said it must still be in [R1’s] room. They then transported [R1] to the hospital! [E1] went straight to [R1's] room to look for it, [E1] moved everything around trying to find it. [E1] then asked the other [residents] did they know where it was and they all said no. [E1] kept looking and speaking to the [residents] about how instrumental it could be to saving [R1's] life if need be. Then [R2] handed me the vape, and [E1] discarded the Vvpe as trash.” 2. In an interview, E2 reported R1's seizure was caused by R1 taking too many Benadryl, which caused hallucinations. E2 reported R1 told the nurse at the emergency room (ER) that R1 stole Benadryl from R1's grandmother's house and ingested multiple Benadryl pills at the facility, which caused the seizure. E2 reported R1 told the nurse at the ER that R1 ingested the pills because it was a "TikTok" challenge. E2 reported E1 didn't provide hospital discharge paperwork to the facility. E2 reported grandmother and DCS guardian have discharge paperwork. 3. In an interview, E2 reported that no written notification was provided to the Department of immediate intervention by an EMS provider for a resident within two working days. 4. In an exit interview, the findings were reviewed with E2, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-708.A.6.a. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 6. Is reviewed and updated on an on-going basis: a. According to the review date specified in the treatment plan,

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was reviewed and updated on an on-going basis according to the review date specified in the treatment plan, for one of three residents sampled. The deficient practice posed a risk as an updated treatment plan was not completed to articulate decisions and agreements of services to be provided.

findings: 1. A review of R1's medical record revealed a treatment plan. The treatment plan stated " ... Monthly Treatment Plan Update - NOV 2025." However, no documentation of an updated treatment plan was available for review. 2. In an interview, E2 reported not having an updated treatment plan from the Behavioral Health Professional available for R1. 3. In an exit interview, the findings were reviewed with E2, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-716.A.7.a. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal history; or

evidence: Based on record review and interview, the administrator failed to ensure a resident did not have access to any materials that may present a threat to the resident's health or safety. The deficient practice posed a risk as R1 gained access to a vape and medication that R1 was not prescribed, and required immediate intervention by emergency medical services.

findings: 1. A review of R1’s medical record revealed a document titled "Incident Report" (dated January 10, 2026). The document stated “[R1] was being placed in an ambulance due to the seizure [R1] had moments before [R1] called out to [E1] before they closed the doors. [E1] looked in and [R1] was patting [R1's] pockets! [E1] asked [R1] what [R1] was looking for? [R1] said [R1] thought [R1] had a vape on [R1]. [E1] asked [R1] whose Vape was it and [R1] said it was [R1’s]. [R1] then said it must still be in [R1’s] room. They then transported [R1] to the hospital! [E1] went straight to [R1's] room to look for it, [E1] moved everything around trying to find it. [E1] then asked the other [residents] did they know where it was and they all said no. [E1] kept looking and speaking to the [residents] about how instrumental it could be to saving [R1's] life if need be. Then [R2] handed me the vape, and [E1] discarded the vape as trash.” 2. In an interview, E2 reported R1's seizure was caused by R1 taking too many Benadryl, which caused hallucinations. E2 reported R1 told the nurse at the emergency room (ER) that R1 stole Benadryl from R1's grandmother's house and ingested multiple Benadryl pills at the facility, which caused the seizure. E2 reported R1 told the nurse at the ER that R1 ingested the pills because it was a "TikTok" challenge. E2 reported E1 didn't provide hospital discharge paperwork to the facility. E2 reported grandmother and DCS guardian have discharge paperwork. 3. In an interview, E2 reported E2 did not know about the vape. E2 reported that R1 recently visited grandmother's house and R1 had been stealing Benadryl from grandmother's house. E2 reported R1’s grandmother knew about the Benadryl and reported R1 had been stealing the medication for about 10 months. E2 reported R1’s grandmother never told E2 or the administrator about the Benadryl being taken from the grandmother's house. E2 reported that when R1 returns from visiting family, a contraband check is done, E2 and the other staff never found anything. E2 reported that E2 does not know where R1 could be hiding the Benadryl or vape. 4. In an exit interview, the findings were reviewed with E2, and no additional comments, statements, or documentation were provided regarding the findings.


summary: Complaint - 1/8/2026

raw_content: The following deficiencies were found during the on-site investigation of complaint 00155390 conducted on January 8, 2026:

evidence: Based on documentation review and interview, the administrator failed to ensure sufficient personnel were present on the behavioral health residential facility's premises with the skills and knowledge necessary to ensure the health and safety of residents. The deficient practice posed a risk to resident health and safety as the administrator failed to ensure the personnel on duty possessed the skills and knowledge necessary to safely manage resident behaviors and emotional outbursts. E1’s lack of demonstrated behavioral-intervention and de-escalation skills during an emergent situation increased the risk of harm to residents.

findings: 1. A review of facility documentation revealed an incident report dated November 5, 2025. The incident report stated, "the residents were doing chores and [E6] was preparing to give out meds [E1] went and checked on the [residents] in the master room because the living room was a bit to quiet and when [E1] came back [E1] made [R2] give [E6] 3 pills [R2] had in [R2's] hand. [E1] told [E6] that when [E1] went in the room it seemed like [R2] was trying to hide them but got caught. When [R2] and [R1] were in the living room [R2] kept nagging at [R1] and telling [R1] to tell staff that [R1] was the one that gave [R2] the pills but [R1] claimed [R1] didn't give them to [R2] and [R2] kept repeating the same thing and [R1] warned [R2] saying "if you keep saying that [sic] on my momma [sic] ima beat [sic] [expletive]” and [R2] kept talking and [R1] said "we can go outside” and [R2] said "i'm not meeting you anywhere” and [R2] proceeded to keep nagging and talking to [R1] and then [R1] started punching [R2] and [R2] was balled up and was in tears after a while after everything happened and things cooled down [E6] asked [R2] what was the situation about the pills and [R2] said that [R1] gave them to [R2] and [R1] has a “plug” aka a dealer that drops things off in the middle of the night and that [R1] is supposed to be receiving a puff bar sometime next week by [R1's] “plug” and that [R1] kept some pills in a bag (when [E6] and [E1] did a room search we didn't find any pills). When [E6] went to go ask [R1] what happened [R1] said that [R2] got the pills from school. [R1] then said “[R1] wouldn't go back and do 90 days for something that [R1] didn't do”. 2. In an interview, the Compliance Office asked E1 if any emergency safety response was used during the incident. E1 stated, “no we told them to stop and they separated." E1 reported no pills were found during a contraband check in the room. E1 reported that when contraband checks are completed, nothing is ever found in the room. 3. In an interview, E2 reported that when E1 took R1 to get a drug test, E1 said R1 was nervous and couldn't pee, so E1 bought R1 an electrolyte drink. E1 reported R1 couldn't get the drug test done, and E1 had to bring R1 back the next day to do the drug test. 4. In an interview, E2 reported that E2 did not know about the incident, and E2 and staff checked the cameras outside the facility and hadn't seen anyone drop anything off. 5. In a joint exit interview, the findings were reviewed with E2 and E5, and no additional comments, statements, or documentation were provided regarding the findings.

rule: R9-10-706.E.2. Personnel E. An administrator shall ensure that: 2. A personnel member completes orientation before providing behavioral health services or physical health services;

evidence: Based on record review and interview, the administrator failed to ensure a personnel member completed orientation before providing behavioral health services or physical health services. The deficient practice posed a risk if personnel members were not oriented to the facility.

findings: 1. A review of E1's personnel record revealed no documentation of orientation. 2. In an interview, E2 reported orientation was completed, but the document was not in E1’s personnel record. E2 could not locate the orientation document. 3. In a joint exit interview, the findings were reviewed with E2 and E5, and no additional comments, statements, or documentation were provided regarding the findings.

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

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's compliance with requirements in A.R.S. § 36-411. The deficient practice posed a risk if E1 was a danger to a vulnerable population.

findings: 1. A review of E1's personnel record revealed no documentation of a fingerprint clearance card. 2. In an interview, E1 reported E1 received the card, but did not have it with E1. The Compliance Officer requested an application number or a photograph of the fingerprint clearance card. However, E1 reported not having a photograph, deleted all 2025 emails, and did not have an application number. 3. A review of the Department of Public Safety's website revealed E1's fingerprint clearance card was not valid. Date received: August 19, 2025; decision date: October 27, 2025. 4. In an interview, E2 reported that E2 did not do the hiring and did not know the fingerprint clearance card was not valid. E2 reported that all hiring documents have been uploaded to the electronic record-keeping system by whoever did the hiring. 5. In an interview, E2 reported E2 spoke with E1 on January 8, 2025 and sent E1 home, E2 reported E1 has been removed from the schedule until E1 can get a valid fingerprint clearance card. 6. In a joint exit interview, E2 and E5 acknowledged E1's fingerprint clearance card was not valid. No additional comments, statements, or documentation were provided regarding the findings.


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

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

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

findings: Arizona Administrative Code (A.A.C.) R9-10-101.155. states "Orientation" means "the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution." 1. A review of facility documentation revealed a policy and procedure titled "ORIENTATION" dated 2024. The policy stated "...Upon hiring, all new hired staff will need to go through our 4-hour training process before working alone." 2. A review of E1's, E2’s, E3’s, and E4’s personnel records revealed no documentation of a completed orientation. 3. In an interview, the administrator reported all staff had completed orientation. However, E1 and the administrator did not document the completed orientation. 4. In an exit interview, the findings were reviewed with the administrator, and no further documentation or comments were provided.

rule: R9-10-722.B.8.c. Physical Plant Standards B. An administrator shall ensure that: 8. A resident bedroom complies with the following: c. Contains a door that opens into a hallway, common area, or outdoors;

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

findings: 1. The Compliance Officer observed three bedrooms in the facility occupied by four residents. However, all three bedrooms did not contain doors. 2. In an interview, E1 reported the bedroom doors had been removed since E1 started working there, and did not know why there were no doors. 3. In an interview, the administrator reported never noticing bedroom doors were missing. The administrator reported the bedroom doors were in the garage. 4. In an exit interview, the findings were reviewed with the administrator, and further comment was not provided.


summary: Initial Monitoring - 2/12/2025

raw_content: The following deficiency was found during the on-site abbreviated follow-up inspection conducted on February 12, 2025:

rule: R9-10-706.K.3.a. Personnel K. An administrator shall ensure that: 3. There is a daily staffing schedule that: a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members;

evidence: Based on documentation review and interview, an administrator failed to ensure there was a daily staffing schedule. The deficient practice posed a risk as there was no staffing schedule to accurately reflect staff present at the facility or on-call personnel members.

findings: 1. The Compliance Officer requested to review the facility's staffing schedule. However, a staffing schedule was not available for review. 2. In an interview, E1 reported there was no daily staffing schedule, as the facility has only one resident. E1 reported E1 worked at the facility alone every day throughout the week. E1 reported E1 slept while R1 went to school during the day, and E1 called in the on-call staff if E1 felt E1 needed more rest.


summary: Compliance (Initial) - 9/20/2024 - 10/21/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on September 20, 2024 and the off-site documentation review completed on October 21, 2024.


facility_name: DENALI YOUTH HOMES OF ARIZONA, LLC

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

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on December 11, 2025:

evidence: Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities, including the individual's freedom from infectious TB. The deficient practice posed a potential TB exposure risk to residents.

findings: "R9-10-113.B.1.c.(i-ii) B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. ii. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101; and Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution." 1. A review of R1's medical record revealed documentation of assessing risks of prior exposure to infectious TB and determining if R1 had signs or symptoms of TB dated December 1, 2025. However, there was no documentation of evidence of freedom from infectious TB. 2. In an interview, E1 reviewed the findings, and no additional documentation was provided for review.

rule: R9-10-707.A.3.b. Admission; Assessment A. An administrator shall ensure that: 3. Except as provided in subsection (A)(4), general consent is obtained from: b. A resident's representative, if the resident is not an adult;

evidence: Based on record review and interview, the administrator failed to ensure general consent was obtained from a resident's representative if the resident was not an adult. The deficient practice posed a risk to the health and safety of residents if a resident's representative did not consent to treatment.

findings: 1. A review of R1's medical record revealed a behavioral health assessment dated August 13, 2025. The assessment stated, "... [R1]... Category: Child/Adolescent... Legal Guardian Information: Grandma; [O1]..." 2. A review of R1's medical record revealed general consent was not obtained. 3. In an interview, E1 reviewed the findings and no additional documentation was provided for review.

rule: R9-10-707.A.10.b. Admission; Assessment A. An administrator shall ensure that: 10. If a behavioral health assessment that complies with the requirements in this Section is received from a behavioral health provider other than the behavioral health residential facility or if the behavioral health residential facility has a medical record for the resident that contains a behavioral health assessment that was completed within 12 months before the date of the resident's current admission: b. The review and update of the resident's assessment information is documented in the resident's medical record within 48 hours after the review is completed;

evidence: Based on record review and interview, the administrator failed to document the review and update of the resident's assessment information within 48 hours after the review was complete. The deficient practice posed a risk to the health and safety of residents if assessments received from another behavioral health residential facility were not reviewed and updated before treatment was provided.

findings: 1. A review of R1's medical record revealed a behavioral health assessment received from another behavioral health provider dated August 13, 2025. However, no documentation of the review and update of R1's assessment information was available for review. 2. In an interview, E1 reviewed the findings and reported E1 was unaware the review had to be documented and maintained in R1's medical record.

rule: R9-10-712.C.5.b.ii. Medical Records C. An administrator shall ensure that a resident's medical record contains: 5. If applicable, the name and contact information of the resident's representative and: b. If the resident's representative: ii. Is a legal guardian, a copy of the court order establishing guardianship;

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained a copy of the court order establishing guardianship. The deficient practice posed a risk to the health and safety of residents if the resident's representative was not the legal guardian.

findings: 1. A review of R1's medical record revealed a behavioral health assessment dated August 13, 2025. The assessment stated, "... Legal Guardian Information: Grandma; [O1]..." 2. A review of R1's medical record revealed no documentation of a court order establishing guardianship was available for review. 3. In an interview, E1 reviewed the findings and reported E1 was unaware the court order needed to be maintained in R1's medical record.

rule: R9-10-716.A.5. Behavioral Health Services A. An administrator shall ensure that: 5. Behavioral health services listed in the behavioral health residential facility's scope of services are provided on the premises;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure behavioral health services listed in the behavioral health residential facility's scope of services were provided on the premises. The deficient practice posed a risk to the health and safety of residents if the facility did not provide any behavioral health services.

findings: 1. A review of facility documentation revealed a policy titled, "Administration 1." The policy stated, "... The scope of services for this Behavioral Health Residential Facility will include: Administration of Medication... Counseling... Monitoring in Daily life Skills... Off-site services..." 2. A review of R1's medical record revealed a treatment plan dated August 15, 2025. The plan stated, "... Program: Outpatient; Services: Individual counseling, group counseling, peer support, case management, group skills development & training, individual skill development & training, victory program, respite care, mentoring, medical services, family support... Referred Services... 3. Outpatient; Individual Counseling; Life Skills/Clinical... 1x+ weekly; 4. Outpatient; Individual Skills Development & Training; Life Skills/Clinical... 3x+ weekly; 5. Outpatient' Group Counseling; Clinical... 3x+ weekly; 6. Group Skills Development & Training; Life Skills... 3x+ weekly; 8. Outpatient; Mentoring; Life Skills... 2x+ weekly; 9. Outpatient; Peer Support; Life Skills... 2x+ weekly..." 3. In an interview, E1 reported R1 had received counseling at the facility. E1 also reported R1 had received some counseling from the behavioral health professional of the referring facility. E1 also reported that E2 had suggested using the behavioral health professional from the referring facility.

rule: R9-10-716.B.2. Behavioral Health Services B. An administrator shall ensure that counseling is: 2. Provided according to the frequency and number of hours identified in the resident's treatment plan, and

evidence: Based on record review and interview, the administrator failed to ensure counseling was provided according to the frequency and number of hours identified in the resident's treatment plan. The deficient practice posed a risk to the health and safety of residents if residents were unable to receive sufficient counseling to address their treatment needs.

findings: 1. A review of R1's medical record revealed a treatment plan dated August 15, 2025. The plan stated, "... Program: Outpatient; Services: Individual counseling, group counseling, peer support, case management, group skills development & training, individual skill development & training, victory program, respite care, mentoring, medical services, family support... Referred Services... 3. Outpatient; Individual Counseling; Life Skills/Clinical... 1x+ weekly; 4. Outpatient; Individual Skills Development & Training; Life Skills/Clinical... 3x+ weekly; 5. Outpatient' Group Counseling; Clinical... 3x+ weekly; 6. Group Skills Development & Training; Life Skills... 3x+ weekly; 8. Outpatient; Mentoring; Life Skills... 2x+ weekly; 9. Outpatient; Peer Support; Life Skills... 2x+ weekly..." However, the treatment plan did not include the number of hours of counseling to be provided. 2. In an interview, E1 reviewed the findings and reported E1 will update the treatment plan to include the number of hours of counseling to be provided.


summary: Initial Monitoring - 12/10/2024

raw_content: The following deficiencies were found during the on-site abbreviated follow-up inspection conducted on December 10, 2024:

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

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a health care institution administered a training program for all staff regarding fall prevention and fall recovery which included initial training and continued competency training for two of six personnel records sampled. The deficient practice posed a risk to the health and safety of residents if employees were unable to implement fall prevention and fall recovery strategies.

findings: 1. A review of facility documentation revealed a policy titled, " Slip and Fall Prevention Program." The policy stated, "... b. The administrator shall develop and implement a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial and continued training in fall prevention and fall recovery... The administer will ensure annual training is provided to all BHT and staff members pertaining to reducing and managing slips and fall concerns..." 2. A review of facility documentation revealed a policy titled, "Personnel 2." The policy stated, "F. The administrator will ensure that each personnel record is maintained in a file that includes... c. The individuals completed orientation and in-service education as required by policies and procedures..." 3. A review of E3's and E4's personnel record revealed documentation of an initial or continued competency training in fall prevention and fall recovery was not available for review. 4. In an exit interview, E2 reported E3 and E4 had completed the fall prevention and fall recovery training but documentation of the training was not maintained in a personnel record.

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

evidence: Based on record review and interview, the administrator failed to ensure documentation of an individuals skills and knowledge was maintained in a personnel record, for one of six personnel records sampled. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of E1's (hired as the administrator and a behavioral health technician) personnel record revealed documentation of E1's skills and knowledge was not available for review. 2. In an exit interview, E2 reported the information was available via email but had not been placed into the personnel records.

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

evidence: Based on record review and interview, the administrator failed to ensure documentation of an individuals education and experience was maintained in a personnel record, for one of six personnel members sampled. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of E1's (hired as the administrator and a behavioral health technician) personnel record revealed no documentation of E1's education and experience available for review. 2. In an exit interview, E2 reported the information was available via email but had not been placed into the personnel record.

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

evidence: Based on record review and interview, the administrator failed to ensure documentation of the individuals completed orientation was maintained in a personnel record for four of six personnel records sampled. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of E1's, E2's, E3's and E4's personnel record revealed documentation of orientation was not available for review. 2. In an exit interview, E2 reported the information was available via email but had not been placed into the personnel records.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10-703(C)(1)(e);

evidence: Based on documentation review, record review and interview, the administrator failed to ensure documentation of cardiopulmonary resuscitation (CPR) training was maintained in a personnel record for one of six personnel records sampled. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of facility documentation revealed a policy titled, " Personnel Qualifications: Behavioral Health Professional, Registered Nurse, Behavioral Health Technician." The policy stated, "... 5.) The administrator will ensure that behavioral health technicians meet the qualifications as outlined in the policies and procedures as follows... Has proof of current CPR and First Aid training that has not expired..." 2. A review of E2's personnel record revealed a CPR training certificate which had expired on November 4, 2024. However, documentation of a current and valid CPR training certificate was not available for review. 3. In an interview, E2 reported E2 was in the process of obtaining a new CPR training certificate.

rule: G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes: 3. Documentation of: i. First aid training, if required for the individual according to this Article or policies and procedures; and

evidence: Based on documentation review, record review and interview, the administrator failed to ensure documentation of first aid training was maintained in a personnel record for two of six personnel records sampled. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of facility documentation revealed a policy titled, " Personnel Qualifications: Behavioral Health Professional, Registered Nurse, Behavioral Health Technician." The policy stated, "... 1. The administrator will ensure that the Behavioral Health Professional meets the qualifications as outlined in A.R.S. Title 32, Chapter 33 who can be a licensed counselor... Must obtain a current and valid fingerprint clearance card, provide documentation confirming free from TB within 1 year, and have valid CPR/First Aid certification... 3.) Registered Nurse must be at least 21 years of age... Must obtain a current and valid fingerprint clearance card, provide documentation confirming free from TB within 1 year, and have valid CPR/First Aid certification..." 2. A review of E3's personnel record revealed a CPR and AED training valid until June 30, 2026. However, documentation of a first aid training was not available for review. 3. A review of E4's personnel record revealed a CPR and AED training valid until August 12, 2025. However, documentation of a first aid training was not available for review. 4. In an exit interview, E2 reported the training was completed but documentation was not maintained in the personnel record.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, a registered dietitian or director of food services shall ensure that: 2. A food menu: c. Is conspicuously posted at least one calendar day before the first meal on the food menu will be served,

evidence: Based on observation and interview, the administrator failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu will be served. The deficient practice posed a risk to the health and safety of residents.

findings: 1. The Compliance Officer observed a posted food menu on the front of the facility refrigerator which stated, " Week 1; Sunday (day 1); Monday (day 2); Tuesday (day 3); Wednesday (day 4); Thursday (day 5); Friday (day 6); Saturday (day 7); 2 Apr 2024..." However, a current food menu posted at least one calendar day before the first meal was not available for review. 2. In an exit interview, E2 acknowledged the food menu was not posted one calendar day before the first meal will be served.

rule: 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 documentation review and interview, the administrator failed to obtain a fire inspection according to the time-frame established by the local fire department or the State Fire Marshal. The deficient practice posed a risk to the health and safety of residents.

findings: 1. A review of facility documentation revealed a fire inspection report issued November 8, 2023 and expired on November 30, 2024. However, documentation of a current fire inspection report was not available for review. 2. In an exit interview, E2 acknowledged the fire inspection report was expired. 3. In an exit interview, E2 reported E2 would inform E1 and get the inspection done as soon as possible.


summary: Compliance (Initial) - 9/26/2024 - 10/21/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on September 26, 2024 and the off-site documentation review completed on October 21, 2024.


facility_name: DALIA HOMECARE MARIPOSA

summary: Complaint - 2/18/2026

raw_content: The following deficiencies were found during the on-site  investigation of complaint 00159332 conducted on February 18, 2026:

rule: R9-10-703.M.1-3. Administration M. An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are available upon request to a personnel member, employee, resident, or a resident's representative: 1. The behavioral health residential facility's current license, 2. The location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review, and 3. The calendar days and times when a resident may accept visitors or make telephone calls.

evidence: Based on observation and interview, the administrator failed to ensure the behavioral health residential facility's current license was conspicuously posted on the premises.

findings: 1. The Compliance Officer observed a posted behavioral health license. However, the license was for BH10297. 2. In an interview, E1 acknowledged the posted license was for a sister facility and not the facility where the inspection was being conducted. 3. In an exit interview, the findings were reviewed with E2 , and E2 reported to be unsure why a different facility's license was posted.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure sufficient personnel members were present on the behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as there was not enough trained personnel members on the premises to safely manage the sudden, intense, or out-of-control behavior of a resident who had to be taken into the hospital.

findings: 1. A review of facility documentation revealed a document titled "Incident Report" dated in February 2026 that stated "[R1] was returned by Phoenix Police Department at approximately 7:00 p.m., about one hour after leaving the facility without authorization (AWOL). Staff informed the officers that we were unable to accept the client back. However, the officers advised that they could not transport [R1] to the hospital or to juvenile detention and stated that we were required to take [R1] back. They did offer to follow this writer if transportation to either location was arranged. This writer explained to the officers that only one staff member was on site and that other clients were present. After this discussion, the officers reiterated that we needed to accept the client back into the facility. Upon returning, the client sat calmly on the couch for approximately 45 minutes. After the officers left, the client began acting out again, stating that [R1] was bored and did not want to be at the facility. Staff attempted to engage [R1] in conversation, but [R1] refused to communicate and subsequently left the premises again without authorization. This writer notified the owner, contacted the Phoenix Police Department again, and completed an additional incident report." 2. A review of facility documentation revealed a daily staffing schedule. The daily staffing schedule revealed on the day of the aforementioned incident, E1 was scheduled to work 7 am - 2 pm, E4 was scheduled to work 2 pm - 10 pm and E1 was scheduled to work again from 10 pm - 8 am. 3. In an interview, E1 reported E1 came to the facility at 10 pm and R1 had AWOLed earlier in the evening, prior to E1 working E1's second shift of the day. E1 reported R1 was later brought back to the facility by police. E1 reported the police refused to take R1 to the hospital and insisted the facility take custody of R1. E1 reported the police agreed to take R1 to the hospital if E1 followed along. E1 reported E1 took the remaining three (3) residents to Mind 24-7 to meet with the police and R1 at 10:30 pm. E1 acknowledged the facility did not have sufficient personnel available so the other 3 residents did not have to go with E1 to the hospital to meet R1 and the police. 4. In an exit interview, the findings were reviewed with E2, and no additional comments or documentation were provided for review.

rule: R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently receives: b. Continuous protective oversight;

evidence: Based on record review, documentation review and interview, the administrator failed to ensure if a behavioral health residential facility was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently, a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a health and safety risk as a resident under the age of 18 left the facility and did not receive continuous protective oversight.

findings: A.R.S. § 36-401.A. 13. "Continuous" means available at all times without cessation, break or interruption. 1. A review of R1's medical record revealed R1 was under the age of 18. 2. A review of facility documentation revealed a document titled "Incident Report," dated in February 2026. The document stated "[R1] was on restrictions and attempted to defy those restrictions. When this writer attempted to hold [R1] accountable [R1] went AWOL walking out the door down the street towards camelback pd reference #is 223143." The document was digitally signed by E4. 3. A review of facility documentation revealed a document titled "Incident Report" dated in February 2026 that stated "[R1] was returned by Phoenix Police Department at approximately 7:00 p.m., about one hour after leaving the facility without authorization (AWOL). Staff informed the officers that we were unable to accept the client back. However, the officers advised that they could not transport [R1] to the hospital or to juvenile detention and stated that we were required to take [R1] back. They did offer to follow this writer if transportation to either location was arranged. This writer explained to the officers that only one staff member was on site and that other clients were present. After this discussion, the officers reiterated that we needed to accept the client back into the facility. Upon returning, the client sat calmly on the couch for approximately 45 minutes. After the officers left, the client began acting out again, stating that [R1] was bored and did not want to be at the facility. Staff attempted to engage [R1] in conversation, but [R1] refused to communicate and subsequently left the premises again without authorization. This writer notified the owner, contacted the Phoenix Police Department again, and completed an additional incident report." 4. A review of facility documentation revealed a hand-written, undated document that stated "[R1] left twice...second time [R1] left [R1] didn't return [sic] he's been gone for 33 mines [sic]." 5. In an interview, E1 reported E1 came onto shift on the evening in question and R1 had AWOLed several times. 6. In an exit interview, the findings were reviewed with E2, and no additional comments or documentation were provided for review.

rule: R9-10-721.A.1.c. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. The premises and equipment are: c. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

evidence: Based on observation, record review and interview, the administrator failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk as possible ligature points and possible dangerous items were identified.

findings: 1. The Compliance Officer observed R1's bedroom (now occupied by R3) closet contained wall-mounted wired shelves and brackets. 2. The Compliance Officer observed R2's and R4's shared bedroom closet contained wall-mounted wired shelves and brackets. 3. The Compliance Officer observed an acrylic bar in R2's and R4's shared bathroom. The acrylic bar did not give way when the Compliance Officer applied downward pressure. 4. The Compliance Officer observed, scattered in the back yard, various items of concern including pieces of broken metal furniture, broken pieces of wood with exposed nails, piles of bricks, rusted pieces of metal and broken shards of wood. 5. A review of R1's medical record revealed R1 had a history of physical aggression, irritability, anxiety and depression. 6. In an interview, E1 reported R1 had an outburst earlier in the week and destroyed several items in the facility, including the items scattered in the backyard. E1 reported R1 had been physically aggressive on multiple occasions, including two days prior and had been taken to Mind 24-7. 7. In an exit interview, the findings were reviewed with E2, and no additional comments or documentation were provided for review.

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 maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents.

findings: 1. The Compliance Officer observed a bottle of Windex underneath the unlocked kitchen sink. The bottle contained a toxic warning label. 2. The Compliance Officer observed a canister of air freshener on a hallway table. The canister contained a toxic warning label. 3. The Compliance Officer observed an unlocked laundry room. The laundry room contained a bottle of multi-purpose cleanser on a laundry room shelf and laundry detergent on top of the dryer. The bottles contained toxic warning labels. 4. The Compliance Officer observed an unlocked garage. The garage contained an unlocked cabinet which contained bottles of multi-purpose cleanser, Windex, bleach and laundry detergent. The containers contained toxic warning labels. 5. The Compliance Officer observed one resident onsite during the inspection. 6. In an interview, E1 acknowledged the poisonous or toxic materials throughout the facility were unlocked and accessible to residents. 7. In an exit interview, the findings were reviewed with E2, and no additional comments or documentation were provided for review.


summary: Initial Monitoring - 2/26/2025

raw_content: The following deficiencies were found during the on-site abbreviated follow-up inspection conducted on February 26, 2025:

rule: A.R.S. § 36-407.A. Prohibited acts; required acts A. A person shall not establish, conduct or maintain in this state a health care institution or any class or subclass of health care institution unless that person holds a current and valid license issued by the department specifying the class or subclass of health care institution the person is establishing, conducting or maintaining. The license is valid only for the establishment, operation and maintenance of the class or subclass of health care institution, the type of services and, except for emergency admissions as prescribed by the director by rule, the licensed capacity specified by the license.

evidence: Based on observation and interview, the administrator failed to maintain in this state a health care institution with the approved capacity, occupancy, and operations of the subclass of health care institution for which the Department issued a valid license. The deficient practice posed a risk as the current capacity, occupancy, and operations of the health care institution were outside the scope of the licensed behavioral health residential facility subclass.

findings: R9-10-101(195) "Resident" means an individual living in and receiving physical health services or behavioral health services, including rehabilitation services or habilitation services if applicable, from a nursing care institution, an intermediate care facility for individuals with intellectual disabilities, a behavioral health residential facility, an assisted living facility, or an adult behavioral health therapeutic home. 1. The Compliance Officer observed O1 answer the door. The Compliance Officer observed three individuals inside the facility. 2. In an interview, O1 reported that there were no residents and no staff on-site at the facility. However, O1 reported O1 was a contracted maintenance worker, and O1 was staying at the facility with O1's two children while completing the maintenance work. O1 reported E2 was letting O1 and O1's two children live at the facility temporarily for the week while O1 completed maintenance work. 3. The Compliance Officer was unable to enter the facility due to the absence of facility staff on the premises. However, the Compliance Officer observed a pile of shoes inside the facility from the front door. The Compliance Officer additionally observed O1 packing up clothes. 4. The Compliance Officer attempted to call the two phone numbers listed for the facility at 11:30 AM on February 26, 2025. However, there was no answer, and the Compliance Officer left voicemails. 5. At 1:15 PM, approximately one hour and 45 minutes after the attempted phone calls, the Compliance Officer received a phone call from E1. E1 confirmed that O1 was a contracted maintenance worker, and O1 was living at the facility while O1 completed maintenance work for the facility. E1 confirmed there were no residents and no staff present at the facility.

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

evidence: Based on documentation review, observation, and interview, the licensee failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

findings: 1. A review of Department documentation revealed the facility's perpetual license was effective in October 2024. 2. The Compliance Officer observed O1 answer the door. The Compliance Officer observed three individuals inside the facility. 3. In an interview, O1 reported there were no residents and no staff on-site at the facility. However, O1 reported O1 was a contracted maintenance worker, and O1 stayed at the facility with O1's two children while completing the maintenance work. O1 reported that E2 was letting O1 and O1's two children live at the facility temporarily for the week while O1 completed maintenance work. 4. The Compliance Officer attempted to call the two phone numbers listed for the facility at 11:30 AM on February 26, 2025. However, there was no answer, and the Compliance Officer left voicemails. 5. At 1:15 PM, approximately one hour and 45 minutes after the attempted phone calls, the Compliance Officer received a phone call from E1. E1 confirmed that O1 was a contracted maintenance worker, and O1 was living at the facility while O1 completed maintenance work for the facility. E1 confirmed there were no residents and no staff present at the facility.


summary: Compliance (Initial) - 10/1/2024 - 10/21/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on October 1, 2024 and the off-site documentation review completed on October 21, 2024.


facility_name: LWB HOLLY HOUSE

summary: Initial Monitoring - 11/14/2025

raw_content: No deficiencies were found during the on-site initial monitoring inspection conducted on November 14, 2025.


summary: Compliance (Annual) - 11/14/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on November 14, 2025:

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

evidence: Based on record review and interview, the administrator failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training in fall prevention and fall recovery. The deficient practice posed a risk to the health and safety of residents if E5 was unable to be safely assisted during a fall.

findings: 1. A review of E5's personnel record revealed no documentation of initial fall prevention and fall recovery training. 2. In an interview, E1 reported E5's completion of the initial training was missed but E5 was scheduled to complete the training on November 20, 2025. 3. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.

evidence: Based on record review and interview, the administrator failed to ensure that counseling was provided according to the number of hours identified in the resident's treatment plan, for two of two resident records sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate the resident’s behavioral health issue at the health care institution.

findings: 1. A review of R1's and R2's medical records revealed treatment plans. The treatment plan for R1 stated, "[R1] will attend Group Counseling 1-2 times per month." R2's treatment plan stated, "[R2] will attend Group Counseling 1-4 times per week." However, the treatment plan did not include the number of hours counseling was to be provided. 2. In an exit interview, the findings were reviewed with E1, and no additional comments, statements, or documentation were provided regarding the findings.


summary: Compliance (Initial) - 11/8/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on November 8, 2024 and the off-site documentation review completed on November 8, 2024.


facility_name: HORIZON RECOVERY DEER VALLEY, LLC

summary: Complaint - 3/23/2026

raw_content: No deficiencies were found during the on-site investigation of complaint 00159360 conducted on March 23, 2026.


summary: Complaint - 1/6/2026

raw_content: The following deficiencies were found during the on-site  investigation of complaints 00153842 and 00155149 conducted on January 6, 2026:

evidence: Based on documentation review and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises to provide the services in the behavioral health residential facility's scope of services. The deficient practice posed a risk as no staff were present at the facility to ensure the health and safety of a resident.

findings: 1. A review of facility documentation revealed an incident report. The incident report dated December 28, 2025 stated, "Description of incident: Upon staff arrival at 6:00 AM, it was immediately observed that all Clients were awake and the house atmosphere felt unusual. Staff entered the house and was promptly approached by multiple Clients reporting that the overnight (night shift) staff had left the premises around 3:00 AM, leaving the house unsupervised. Clients also stated that the office was left unlocked and the facility keys had been left out in the open... Action Taken: Client Safety: Staff conducted a head count to verify that all Clients were present and safe. Medication Check: Staff immediately conducted a full medication count, including controlled substances. All medications and sharps were accounted for with no discrepancies. Supervisor Notification: Multiple attempts were made to contact available supervisors. The scheduled supervisor was reached and responded to the house as quickly as possible. Law Enforcement: The Sherriff's Department arrived to perform a welfare check. The responding supervisor communicated with them directly. Leadership Escalation: Due to the urgency and failure to reach other supervisory contacts, Staff also notified Brian to ensure leadership was made aware." 2. In an interview, E1 reported that E6 (hired as a behavioral health technician) was the overnight personnel mentioned in the incident report. E1 reported E6 was terminated the date of the incident and the facility wanted to implement a check-in system for the staff to make sure staff are present at the facility. 3. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.

rule: R9-10-706.K.1. Personnel K. An administrator shall ensure that: 1. At least one personnel member is present and awake at the behavioral health residential facility when a resident is on the premises;

evidence: Based on documentation review and interview, the administrator failed to ensure at least one personnel member was present and awake at the behavioral health residential facility when a resident was on the premises. The deficient practice posed a risk as no personnel member was present and awake to meet the needs and ensure the health and safety of residents.

findings: 1. A review of facility documentation revealed an incident report. The incident report dated December 28, 2025, stated, "Description of incident: Upon staff arrival at 6:00 AM, it was immediately observed that all Clients were awake and the house atmosphere felt unusual. Staff entered the house and was promptly approached by multiple Clients reporting that the overnight (night shift) staff had left the premises around 3:00 AM, leaving the house unsupervised. Clients also stated that the office was left unlocked and the facility keys had been left out in the open... Action Taken: Client Safety: Staff conducted a head count to verify that all Clients were present and safe. Medication Check: Staff immediately conducted a full medication count, including controlled substances. All medications and sharps were accounted for with no discrepancies. Supervisor Notification: Multiple attempts were made to contact available supervisors. The scheduled supervisor was reached and responded to the house as quickly as possible. Law Enforcement: The Sherriff's Department arrived to perform a welfare check. The responding supervisor communicated with them directly. Leadership Escalation: Due to the urgency and failure to reach other supervisory contacts, Staff also notified Brian to ensure leadership was made aware." 2. In an interview, E1 reported that E6 (hired as a behavioral health technician) was the overnight personnel mentioned in the incident report. E1 reported E6 was terminated the date of the incident, and the facility wanted to implement a check-in system for the staff to make sure staff are present at the facility. 3. In a joint exit interview, the findings were reviewed with E1 and E2, and no additional comments or statements were provided regarding the findings.

evidence: Based on documentation review and interview, the administrator failed to ensure that residents admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as residents of the children's behavioral health residential facility were not supervised by the facility personnel at all times.

findings: 1. A review of facility documentation revealed an incident report. The incident report dated December 28, 2025, stated, "Description of incident: Upon staff arrival at 6:00 AM, it was immediately observed that all Clients were awake and the house atmosphere felt unusual. Staff entered the house and was promptly approached by multiple Clients reporting that the overnight (night shift) staff had left the premises around 3:00 AM, leaving the house unsupervised. Clients also stated that the office was left unlocked and the facility keys had been left out in the open... Action Taken: Client Safety: Staff conducted a head count to verify that all Clients were present and safe. Medication Check: Staff immediately conducted a full medication count, including controlled substances. All medications and sharps were accounted for with no discrepancies. Supervisor Notification: Multiple attempts were made to contact available supervisors. The scheduled supervisor was reached and responded to the house as quickly as possible. Law Enforcement: The Sherriff's Department arrived to perform a welfare check. The responding supervisor communicated with them directly. Leadership Escalation: Due to the urgency and failure to reach other supervisory contacts, Staff also notified Brian to ensure leadership was made aware." 2. In an interview, E1 reported that E6 (hired as a behavioral health technician) was the overnight personnel mentioned in the incident report. E1 reported E6 was terminated the date of the incident, and the facility wanted to implement a check-in system for the staff to make sure staff are present at the facility. 3. In a joint exit interview, the findings were reviewed with E1 and E2 and no additional comments or statements were provided regarding the findings.


summary: Compliance (Initial) - 11/20/2024

raw_content: No deficiencies were found during the on-site initial inspection conducted on November 20, 2024.


facility_name: OPEN HEARTS

summary: Compliance (Initial) - 1/2/2025 - 1/15/2025

raw_content: No deficiencies were found during the on-site initial inspection conducted on January 2, 2025 and the off-site documentation review completed on January 15, 2025.


summary: Complaint - 12/2/2025

raw_content: No deficiencies were found during the on-site  investigation of complaint 00152011 conducted on December 2, 2025.


summary: Compliance (Initial) - 11/20/2024

raw_content: No deficiencies were found during the on-site change of ownership inspection conducted on November 20, 2024.


facility_name: ADVANCED BEHAVIORAL HEALTH LLC

summary: Compliance (Initial) - 1/15/2025 - 2/13/2025

raw_content: No deficiencies were found during the on-site initial inspection conducted on January 15, 2025 and the off-site documentation review, conducted on Ferbuary 13, 2024.


facility_name: EMOTICARE RIMROCK, LLC

summary: Complaint - 2/9/2026

raw_content: No deficiencies were found during the on-site  investigation of complaint 00156985 conducted on February 9, 2026.


summary: Complaint - 1/6/2026

raw_content: No deficiencies were found during the on-site investigation of complaint 00155153 conducted on January 6, 2026.