facility_name: NEW HOPE OF ARIZONA, INC

summary: Compliance (Annual) - 10/24/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on October 24, 2025.


state: AZ

summary: Compliance (Annual) - 10/22/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on October 22, 2024:

inspection_type: Compliance (Annual)

rule: A. An administrator shall ensure that: 1. A resident is admitted based upon: a. The resident's primary condition for which the resident is admitted to the behavioral health residential facility being a behavioral health issue, and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident was admitted based upon the resident's primary condition being a behavioral health issue, for one of two residents sampled who's primary condition was not a behavioral health issue. The deficient practice posed a risk if R2's primary condition was a physical health issue.

findings: R9-10-101.32. "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. 1. A review of Department documentation revealed BH5603 was licensed as a Behavioral Health Residential Facility authorized to provide respite services. 2. A review of facility documentation revealed a policy and procedure titled "Scope of Service." The policy and procedure stated, "Behavioral Health Residential Services provides a structured treatment setting with 24 hour supervision and counseling or other therapeutic activities for members who do not require on site medical services, under the supervision of an on call behavioral health professional..." 3. A review of R2's medical record revealed a behavioral health assessment dated in 2022. The behavioral health assessment revealed R2's diagnoses included; F34.81 Disruptive Mood Dysregulation order, F84 Autism Spectrum Disorder." R2's medical record revealed an updated assessment dated in 2023, reflecting "Assessment/Diagnosis F84.0 Autism Spectrum Disorder, F34.81 Disruptive Mood Dysregulation Order, Other Problems related to psychosocial circumstances." R2's medical record did not reveal any incident reports. 4. In an interview, E1 reported R2 was admitted prior to the facility understanding Autism Spectrum Disorder diagnosis was not within the facilities scope of services. E1 reported the facility was currently working on transitioning resident's with this diagnosis to appropriate providers. E1 acknowledged R2's medical records revealed no additional diagnoses. E1 acknowledged the administrator failed to ensure a resident was admitted based on the resident's primary condition for which the resident was admitted was a behavioral health issue.

rule: 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 developed and implemented for each resident and was reviewed and updated on an on-going basis according to the review date specified in the treatment plan. The deficient practice posed a health risk as a treatment plan was not completed to articulate decisions and agreements of services to be provided.

findings: 1. A review of R2's medical record revealed a treatment plan dated October 13, 2023. The treatment plan indicated a review date of "October 13, 2024." However, an updated treatment plan was not available for review. 2. In an interview, E1 reviewed R2's medical record. E1 acknowledged R2's 2023, treatment plan was the most current treatment plan. E1 acknowledged R2's treatment plan was not reviewed and updated according to the review date specified in the treatment plan.


summary: Compliance (Annual) - 12/8/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on December 8, 2023:

rule: 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 if the residents admitted to the residential facility did not receive the behavioral health services expected to be provided on the premises.

findings: 1. A review of the facility policies and procedures revealed a scope of services. The scope of services stated, "...Behavioral Health Residential Services provides a structured treatment setting with twenty four hour supervision and counseling..." 2. A review of R1's and R2's treatment plans revealed no documentation of counseling identified in the residents medical record. 3. In an interview, E1 reported the identified facility residents receive respite services. E1 acknowledged the facility is licensed as a behavioral health residential facility. E1 acknowledged the behavioral health services listed in the behavioral health residential facility's scope of services were not provided on the premises.

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 registered dietitian 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 if the dietary guidelines per R9-10-719(B)(4), were not followed.

findings: 1. The Compliance Officer observed a food menu posted at the facility. However, the menu identified a date of "November 26, 2023, through December 2, 2023." 2. In an interview, E1 acknowledged a food menu was not conspicuously posted at least one calendar day before the first meal on the food menu would be served.


facility_name: OUR HOUSE RESIDENTIALS

summary: Complaint - 5/30/2024

raw_content: An on-site investigation of complaint AZ00210877 was conducted on May 30, 2024 and the following deficiencies were cited :

inspection_type: Complaint

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

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

findings: 1. A review of R2's medical record revealed documentation of a behavioral health assessment (per R9-10-707(A)(11) was not available for review. 2. The Compliance Officer requested, on May 30, 2024 at 8:50AM, to review R2's behavioral health assessment (per R9-10-707(A)(11)). However, R2's behavioral health assessment (per R9-10-707(A)(11) was not provided for review within two hours after a Department request. 3. In an interview, E1 acknowledged R2's behavioral health assessment (per R9-10-707(A)(11) was not provided to the Department within two hours after a Department request.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 2. Is completed: b. Before the resident receives physical health services or behavioral health services or within 48 hours after the assessment is completed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident and was completed before the resident received behavioral health services, for one of three residents sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements before treatment was initiated.

findings: 1. A review of R3's (admitted in 2024) medical record revealed a treatment plan (dated approximately seventeen days after R3's date of admission). 2 A review of R3's medical record revealed medication administration records (MAR) for March 2024 and April 2024. The MARs documented R3 received medication services. 3. In an interview, E1 reported the treatment plan in R3's medical record was the initial treatment plan. E1 acknowledged a treatment plan was not developed and completed before the resident received behavioral health services.

rule: A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: a. The resident's presenting issue; b. The physical health services or behavioral health services to be provided to the resident; c. The signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign; d. The date when the resident's treatment plan will be reviewed; e. If a discharge date has been determined, the treatment needed after discharge; and f. The signature of the personnel member who developed the treatment plan and the date signed;

evidence: Based on record review and interview, the administrator failed to ensure a treatment was developed for each resident to include the behavioral health services to be provided to the resident; the signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign; and the date when the resident's treatment plan will be reviewed; for three of three residents sampled. The deficient practice posed a risk as a treatment plan was not developed to articulate accurate decisions and agreements of services to be provided.

findings: 1. A review of R1's (admitted in 2024) medical record revealed a treatment plan (dated in March 2024). However, the treatment plan did not include the signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign; and the date when the resident's treatment plan will be reviewed. 2. A review of R2's (admitted in 2024) medical record revealed a treatment plan (dated in April 2024). However, the treatment plan did not include the behavioral health services to be provided to the resident; the signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign; and the date when the resident's treatment plan will be reviewed. 3. A review of R3's (admitted in 2024) medical record revealed a treatment plan (dated in March 2024). However, the treatment plan did not include the behavioral health services to be provided to the resident; the signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign; and the date when the resident's treatment plan will be reviewed. 4. In a joint interview, E1 and E2 acknowledged treatment plans were not developed for each resident to include the behavioral health services to be provided to the resident; the signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign; and the date when the resident's treatment plan will be reviewed

rule: C. An administrator shall ensure that a resident's medical record contains: 11. Assessment;

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained an assessment, for one of two discharged residents sampled. The deficient practice posed a risk if an analysis of the resident's needs for behavioral health services to determine which services a health care institution would provide was not completed.

findings: 1. A review of R2's (admitted in 2024) medical record revealed a behavioral health assessment (per R9-10-707(A)(11)) was not available for review. 2. A review of R2's medical record revealed a document titled "Clinical Recommendations" (dated in 2024). The document stated "Upon review of clinical documentation, the client is an appropriate for treatment at OHR Therapeutic Group Home. Per clinical documentation youth will need support ..." However, documentation of a behavioral health assessment in compliance with the requirements in R9-10-707(A)(11) was not available for review. 3. A review of R2's medical record revealed documents titled "Adult/Child and Family Meeting Summary" (dated in 2024). However, documentation of a behavioral health assessment in compliance with the requirements in R9-10-707(A)(11) was not available for review. 4. In an interview, E1 reported the facility's behavioral health professional reviewed R2's clinical documentation before admitting R2. 5. In an interview, E1 reported R2's behavioral health assessment was completed by the behavioral health professional but was not available for review.

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

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

findings: R9-10-101(24) "Assistance in the self-administration of medication" means restricting a patient's access to the patient's medication and providing support to the patient while the patient takes the medication to ensure that the medication is taken as ordered. 1. A review of facility documentation revealed a scope of services (date unavailable). The scope of services stated "... Our House Will Provide: 1. Assistance in the self-administration of medication." 2. A review of R3's (admitted in 2024) medical record revealed a treatment plan (dated in March 2024). However, the treatment plan did not include whether assistance in the self-administration of medication was to be provided to the resident. 3. A review of R3's medical record revealed medication administration records (MAR) for March 2024 and April 2024. The MARs documented R3 received medication services on the following dates: -"Clonidine HCL 0.1mg Take 1 tablet by mouth daily:" March 14-30, 2024; April 3-30, 2024; -"Dextroamp-amphethamin [generic for Adderall] 5mg Take 1 tablet by mouth daily:" March 14, 2024; March 16-23, 2024; March 25-30, 2024; April 3-12, 2024; April 14-15, 2024; -"Dextroamp-amphethamin [generic for Adderall] 10mg Take 1 tablet by mouth daily:" March 14, 2024; March 16-30, 2024; April 3-30, 2024; -"Divalproex 250mg Take 1 tablet by mouth daily:" March 14, 2024; March 16-30, 2024; and -"Divalproex 250mg Take 1 tablet in AM & 2 tablets PM by mouth daily:" April 4-30, 2024 (1 tablet in AM); April 3-30, 2024 (2 tablets in PM). However, medication orders for the aforementioned medications were not available for review. 4. A review of R3's medical record revealed medication orders (dated February 21, 2024) for the following medications: -"Adderall XR 20mg capsule, extended release take 1 capsule by oral route every day in the morning upon awakening;" and -"Clonidine HCl 0.1mg tablet take \'bd tablet by oral route in the morning, \'bd at noon, and 1 tablet after school;" However, documentation to demonstrate R3 was provided Adderall 20mg in the morning and Clonidine 0.1mg, \'bd tablet in the morning, \'bd tablet at noon, and 1 tablet after school was not available for review. 5. In an interview, E1 acknowledged assistance in the self-administration of medication provided to R3 was not in compliance with an order.

rule: B. An administrator shall ensure that: 8. A resident bedroom complies with the following: b. Is not used as a passageway to another bedroom or bathroom unless the bathroom is for the exclusive use of an individual occupying the bedroom;

evidence: Based on observation and interview, the administrator failed to ensure a resident bedroom was not used as a passageway to another bedroom or bathroom.

findings: 1. The Compliance Officer observed a bathroom located in a resident's bedroom. The bedroom was occupied by three residents. The Compliance Officer observed a sign conspicuously posted on the bathroom door. The sign stated "Notice Staff Only." The Compliance Officer observed the bathroom door was locked. 2. In an interview, E2 reported the bathroom was only used by employees. 3. In a joint interview, E1 and E2 acknowledged a resident bedroom was being used as a passageway to a bathroom.


summary: Complaint;Compliance (Annual) - 4/9/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00193603 conducted on April 9, 2024:

inspection_type: Complaint;Compliance (Annual)

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 health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery including initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

findings: 1. A review of facility documentation revealed a PDF of policy and procedures dated October 2020(revised 2022). However a training program in fall prevention and fall recovery was not available for review. 2. A review of E6's personnel record revealed documention for initial training and continued training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 reported training in fall prevention and fall recovery for E6 was not conducted. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 7, 2023.

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); i. First aid training, if required for the individual according to this Article or policies and procedures; and

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training, if required for the individual according to R9-10-703(C)(1)(e), and first aid training, for one of three behavioral health technicians sampled. The deficient practice posed a risk if E4 was unable to meet a resident's needs during an emergency or during an accident.

findings: 1. A review of E4's (hired as a behavioral health technician) personnel record revealed documentation of CPR and first aid training. However, the training had expired in March 2024. 2. In an interview, E1 acknowledged documentation of current CPR and first aid training was not available for review and was unsure if E4 had taken another CPR and first aid training.

rule: A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 2. A pest control program that complies with A.A.C. R3-8-20l(C)(4) is implemented and documented;

evidence: Based on documentation review and interview, the administrator failed to ensure a pest control program in compliance with A.A.C. R3-8-20l(C)(4) was documented.

findings: R3-8-201.C.4. Applicator licensure. An individual may not provide pest management services at a school, child care facility, health care institution, or food-handling establishment unless the individual is a certified applicator in the certification category for which services are being provided. 1. The Compliance Officer requested to review the facility's current pest control documentation. However, a pest control service program, invoice or contract was not provided for review. 2. In an interview, E1 acknowledged the facility did not have a pest control program documented.


facility_name: TREE OF LIFE ARIZONA

summary: Compliance (Annual) - 4/3/2026

raw_content: No deficiencies were found during the on-site compliance inspection conducted on April 3, 2026.


summary: Complaint - 4/2/2025

raw_content: An on-site investigation of complaint AZ00124860 was conducted on April 2, 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 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 only one personnel member was present at the facility when three residents, admitted to the behavioral health residential facility with limited ability to function independently, were able to abscond from the facility.

findings: 1. A review of R1's medical record revealed an incident report dated in March 2025. The incident report stated, "...The residents went to bed at 9:30 p.m. Overnight staff [E1] noted that [R1] had [R1's] shoes on and was standing in the room when [R1] should have been in bed. [R1] attempted to tell [E1] that [they sleep] with [their] shoes on. [E1] attempted to discourage [R1] from absconding. Unfortunately, [R1] and peer [R2] absconded together. A couple of minutes later, [R3] absconded...[R1] returned at about 4 a.m. [R1] seemed skeptical about coming into the home as [R1] tried to convince [R2] to stay out with [R1]. However, after [R2] refused to remain outside, [R1] came in." The report indicated that R1's parents, the high-needs case manager, and the probation officer were notified of the incident within thirty minutes to an hour. 2. A review of R2's medical record revealed an incident report dated in March 2025. The incident report stated, "The residents went to bed at 9:30 p.m. Overnight staff [E1] noted that [R1] had [their] shoes on and was standing in the room when [R1] should have been in bed. [R1] attempted to tell [E1] that they sleep] with [their] shoes on. [E1] attempted to discourage [R1] from absconding. [E1] noted that [R2] was awake and appeared to be interested in what they were discussing. Unfortunately, [R1] and [R2] absconded together." The report indicated that R1's parents, the high-needs case manager, and the probation officer were notified of the incident within thirty minutes to an hour. 3. A review of R3's medical record revealed an incident report dated in March 2025. The incident report stated, "The residents went to bed at 9:30 p.m. Overnight staff [E1] noted that peer [R1] had [their] shoes on and was standing in the room when [R1] should have been in bed. [E1] attempted to discourage [R1] from absconding. Unfortunately, [R1 and peer [R2] absconded together. A couple of minutes later, [R3] tried to abscond. [R3] stated to [E1] that [R3] was leaving to go and get a pair of [R3's] shoes because [R2] or [R1] took them....[R3] remains on the run." The report indicated R3's parents, high needs case manager, and probation officer were notified of the incident within thirty minutes to an hour. 4. A review of the facility's undated policies and procedures revealed a policy titled "Personnel." The subcategory of the policy titled "Behavioral Health Technician" stated, "...Must be able to implement treatment goals and objectives and adhere to all facility’s policies and procedures..." 5. A review of the facility's daily staffing schedules revealed E1, a behavioral health technician, was the sole personnel member on the premises at the time of the aforementioned incidents. The daily staffing schedules did not include on-call personnel. 6. A review of the facility's policies and procedures revealed an undated policy titled "[Absent Without Leave]/Absconding." The policy stated, "A resident that leaves the premises without permission, especially in a hurridely manner or secretly is considered AWOL [Absent Without Leave] status. If a staff member suspects that a resident is contemplating to abscond/AWOL, they will process with the resident, continue to monitor the resident and notify administration. If the resident confirms that they plan to abscond, crisis will be notified, so that further assessment can be completed, to determine if the resident is a danger to themselves. In the event that a resident absconds staff will follow outside to determine the direction the resident went. If the resident begins to run, staff will not chase them, as that may cause more of an unsafe environment. Staff will notify the administrator, police, child protective services, and parent/guardian within 30 minutes to [one] hour. An incident report will be written and maintained in the resident's record." However, E1 did not adhere to the facility's policies and procedures because E1 did not contact crisis or the administrator when E1 became aware of the resident's plan to abscond. 7. In an interview, E6 reported to believe one personnel member present on the premises was sufficient to meet the needs of R1, R2, and R3, at the time they absconded. 8. In an exit interview, E6 and E7 reported E1 had the qualifications, education, skills, knowledge, and experience to meet the needs of R1, R2, and R3 despite the residents' successful absconding from the residence. The findings were discussed with E6 and E7 and no additional comments or documentation were provided.

rule: R9-10-706.G.3.h. 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: h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10-703(C)(1)(e);

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 cardiopulmonary resuscitation training (CPR), for one of six personnel records sampled. The deficient practice posed a risk if E2 was unable to meet a resident's needs in an emergency or accident.

findings: 1. A review of E2's personnel record revealed no documentation of CPR training. 2. A review of the facility's policies and procedures revealed an undated policy titled "Content of a Personnel File." The policy stated, "Each employee's file may contain, but not limited to: Personnel Information Sheet, W2, Employment Eligibility Verification...CPR/[First] Aid Training documentation." 3. In an interview, E6 and E7 reported E2 was scheduled to complete CPR training on April 7, 2025. 4. In an exit interview, E6 and E7 acknowledged E2's personnel record did not include documentation of CPR training.

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 documentation review, record 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 three residents, who required continuous protective oversight due to their limited ability to function independently, were able to abscond from the facility.

findings: 1. A review of Department documentation revealed the facility was licensed to provide services to individuals under the age of 18 years old. 2. A review of R1's medical record revealed an incident report dated in March 2025. The incident report stated, "...The residents went to bed at 9:30 p.m. Overnight staff [E1] noted that [R1] had [R1's] shoes on and was standing in the room when [R1] should have been in bed. [R1] attempted to tell [E1] that [they sleep] with [their] shoes on. [E1] attempted to discourage [R1] from absconding. Unfortunately, [R1] and peer [R2] absconded together. A couple of minutes later, [R3] absconded...[R1] returned at about 4 a.m. [R1] seemed skeptical about coming into the home as [R1] tried to convince [R2] to stay out with [R1]. However, after [R2] refused to remain outside, [R1] came in." The report indicated R1's parents, high needs case manager, and probation officer were notified of the incident within thirty minutes to an hour. 3. A review of R2's medical record revealed an incident report dated in March 2025. The incident report stated, "The residents went to bed at 9:30 p.m. Overnight staff [E1] noted that [R1] had [their] shoes on and was standing in the room when [R1] should have been in bed. [R1] attempted to tell [E1] that they sleep] with [their] shoes on. [E1] attempted to discourage [R1] from absconding. [E1] noted that [R2] was awake and appeared to be interested in what they were discussing. Unfortunately, [R1] and [R2] absconded together." The report indicated that R1's parents, the high-needs case manager, and the probation officer were notified of the incident within thirty minutes to an hour. 4. A review of R3's medical record revealed an incident report dated in March 2025. The incident report stated, "The residents went to bed at 9:30 p.m. Overnight staff [E1] noted that peer [R1] had [their] shoes on and was standing in the room when [R1] should have been in bed. [E1] attempted to discourage [R1] from absconding. Unfortunately, [R1 and peer [R2] absconded together. A couple of minutes later, [R3] tried to abscond. [R3] stated to [E1] that [R3] was leaving to go and get a pair of [R3's] shoes because [R2] or [R1] took them....[R3] remains on the run." The report indicated that R1's parents, the high-needs case manager, and the probation officer were notified of the incident within thirty minutes to an hour. 5. A documentation review of the facility's daily staffing schedules revealed E1, a behavioral health technician, was the sole personnel member on the premises at the time of the aforementioned incidents. 6. A review of the facility's policies and procedures revealed an undated policy titled "[Absent Without Leave]/Absconding." The policy stated, "A resident that leaves the premises without permission, especially in a hurriedly manner or secretly is considered AWOL [Absent Without Leave] status. If a staff member suspects that a resident is contemplating to abscond/AWOL, they will process with the resident, continue to monitor the resident and notify administration. If the resident confirms that they plan to abscond, crisis will be notified, so that further assessment can be completed, to determine if the resident is a danger to themselves. In the event that a resident absconds staff will follow outside to determine the direction the resident went. If the resident begins to run, staff will not chase them, as that may cause more of an unsafe environment. Staff will notify the administrator, police, child protective services, and parent/guardian within 30 minutes to [one] hour. An incident report will be written and maintained in the resident's record." However, the policy and procedure did not include how the facility would provide continuous protective oversight. 7. A documentation review revealed a form titled "Overnight Location Log (dated in March 2025)." The log indicated "bed checks" were conducted with R1 and R2 every 15 minutes and "Absent without Leave [AWOL]," as marked at 10:45 p.m. "Bed checks" were also conducted with R3, and "AWOL" was marked at 11:00 pm on the same date. 8. In an interview, E6 reported having implemented the facility's policies by not "running after" the residents after they absconded to avoid a more unsafe environment for the residents. However, the facility's policies and procedures did not include how the facility would provide continuous protective oversight. 9. In an exit interview, E6 and E7 reported to believe R1, R2, and R3 received protective oversight before absconding from the facility, as evidenced by E1's attempts to dissuade R1 from absconding and "bed checks" every quarter of an hour.


summary: Compliance (Annual) - 1/28/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on January 28, 2025.


summary: Complaint;Compliance (Annual) - 2/8/2024

raw_content: The following deficiency was found during the on-site compliance inspection and investigation of complaint AZ00203946 conducted on February 8, 2024:

rule: 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: a. The resident's assessment information is reviewed before treatment for the resident is initiated and updated if additional information that affects the resident's assessment is identified, and

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment received from a behavioral health provider, completed within 12 months before the date of the resident's current admission, was reviewed before treatment for the resident was initiated and updated if additional information that affects the resident's assessment was identified, for two of three residents sampled.

findings: 1. A review of R1's (admitted in 2024) medical record revealed a behavioral health assessment (dated in November 2023), received from R1's former behavioral health provider. The assessment was dated within twelve months prior to R1's admission. The documentation met the criteria in R9-10-708.A.8. However, facility documentation to indicate this assessment information was reviewed by E2 before treatment for R1 was initiated and updated was not available for review. 2. A review of R2's (admitted in 2023) medical record revealed a behavioral health assessment (dated in October 2023), received from R1's former behavioral health provider. The assessment was dated within twelve months prior to R2's admission. The assessment met the criteria in R9-10-708.A.8. However, facility documentation to indicate this assessment information was reviewed by E2 before treatment for R2 was initiated and updated was not available for review. 3. A review of R1's medical record revealed a group counseling note dated in January 2024 and a family counseling note dated in January 2024. 4. A review of R2's medical record revealed a group and individual counseling note, both dated in October 2023 5. In a joint interview, E4 and E6 acknowledged the behavioral health assessments conducted prior to R1's and R2's admission were not reviewed and updated prior to R1 and R2 receiving treatment.


summary: Compliance (Annual) - 1/30/2026

raw_content: No deficiencies were found during the on-site compliance inspection conducted on January 30, 2026.


summary: Compliance (Annual) - 1/22/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on January 22, 2025.


summary: Compliance (Annual) - 2/27/2024

raw_content: This revised Statement of Deficiencies supersedes the previous Statement of Deficiencies for event ID ZZX211. The following deficiencies were found during the on-site compliance inspection conducted on February 27, 2024:

rule: A. An administrator shall ensure that: 1. A resident is admitted based upon: a. The resident's primary condition for which the resident is admitted to the behavioral health residential facility being a behavioral health issue, and

evidence: Based on record review and interview, the administrator failed to ensure a resident was admitted based upon the resident's primary condition being a behavioral health issue, for two of three residents sampled who's primary condition was not a behavioral health issue. The deficient practice posed a risk if R1's primary condition was a physical health issue.

findings: R9-10-101.32. "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. 1. A review of Department documentation revealed BH5762 was licensed as a Behavioral Health Residential Facility authorized to provide respite services. 2. A review of facility documentation revealed a policy and procedure titled "Scope of Service." The policy and procedure stated, "Behavioral Health Residential Services provides a structured treatment setting with 24 hour supervision and counseling or other therapeutic activities for members who do not require on site medical services, under the supervision of an on call behavioral health professional...." 3. A review of R1's medical record revealed a behavioral health assessment (dated in 2022). The assessment stated "Developmental D/O SPEECH LANGUAGE UNS, Pervasive developmental disorder, unspecified" as the diagnoses. 4. A review of R2's medical record revealed a behavioral health assessment (dated in 2022). The assessment stated "Developmental D/O SPEECH LANGUAGE UNS." No additional diagnoses were available for review. 5. In an interview, E1 reported E1 believed R1's and R2's diagnosis was a behavioral health diagnosis. E1 acknowledged R1's and R2's medical records revealed no additional diagnoses. E1 acknowledged the administrator failed to ensure a resident was admitted based on the resident's primary condition for which the resident was admitted was a behavioral health issue.

rule: A. An administrator shall ensure that: 11. A behavioral health assessment: a. Documents a resident's: i. Presenting issue; ii. Substance abuse history; iii. Co-occurring disorder; iv. Legal history, including: (1) Custody, (2) Guardianship, and (3) Pending litigation; v. Criminal justice record; vi. Family history; vii. Behavioral health treatment history; viii. Symptoms reported by the resident; and ix. Referrals needed by the resident, if any;

evidence: Based on record review and interview, the administrator failed ensure a behavioral health assessment documented a resident's legal history, including: custody, guardianship, pending litigation; criminal justice record, behavioral health treatment history, and symptoms reported by the resident, for two of three residents sampled.

findings: 1. A review of R1's and R2's medical records revealed behavioral health assessment completed by Bayless Integrated Health Services and reviewed by the facility dated in 2022. However, R1's and R2's behavioral health assessments did not include the following: -Legal history; -Behavioral health treatment history; and -symptoms reported by the resident. 2. In an interview, E1 acknowledged R1's and R2's behavioral health assessments did not document all required components.

rule: E. If a behavioral health residential facility is authorized to provide respite services, an administrator shall ensure that: 1. Upon admission of a resident for respite services: a. Except as provided in subsection (F), a medical history and physical examination of the resident: i. Is performed; or ii. If dated within the previous 12 months, is available in the resident's medical record from a previous admission to the behavioral health residential facility;

evidence: Based on record review and interview, the administrator failed to ensure upon admission of a resident for respite services, a medical history and physical examination of the resident was performed. The deficient practice posed a risk if the facility was unable to meet the needs of a resident.

findings: 1. A review of R2's medical record revealed documentation of a medical history and physical examination or a nursing assessment was completed one year after R2's admission. 2. A review of R3's medical record revealed documentation of a medical history and physical examination or a nursing assessment was completed six days after R3's admission. 3. In an interview, E2 acknowledged R2's and R3's documentation of a medical history and physical examination was not completed at admission for R2 and R3 receiving respite services.

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 for one of three residents sampled. The deficient practice posed a risk if the residents admitted to the residential facility did not receive the behavioral health services expected to be provided on the premises.

findings: 1. A review of the facility policies and procedures revealed a scope of services. The scope of services stated, "...Behavioral Health Residential Services provides a structured treatment setting with twenty four hour supervision and counseling..." 2. A review of R2's medical record revealed a treatment plan. The treatment plan did not include counseling services to be provided to R2. 3. In an interview, E1 reported R2 received respite services. E1 acknowledged the facility is licensed as a behavioral health residential facility however the facility accepts only respite residents at this time. E1 acknowledged the behavioral health services listed in the behavioral health residential facility's scope of services were not provided on the premises for R2.

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

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

findings: 1. The Compliance Officer observed the facilities identified room to provide privacy for a resident. However, the room contained the facilities chemicals in an unlocked cabinet. At the time of the inspection, the locking mechanism was not working and the following chemicals were assessable in the privacy room; Laundry Detergent, Bleach, Clorox Disinfectant Spray and Wipes. The privacy room did have a lock to enter. 2. In an interview, E1 acknowledged E1 attempted to lock the toxic chemical cabinet, however the lock would not work. E1 acknowledged the facilities privacy room contained toxic chemicals that would be accessible to residents using the room for treatment or visitors.


facility_name: BACK TO LIFE, INCORPORATED

summary: Compliance (Annual) - 9/8/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on September 8, 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 ensure the healthcare institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included the initial training and continued competency training in fall prevention and fall recovery, for four of six personnel sampled. The deficient practice posed a health and safety risk if personnel were not trained in fall prevention and fall recovery.

findings: 1. A review of E1's and E4's personnel records revealed no evidence of initial training and continued competency training in fall prevention and fall recovery. 2. A review of E2's personnel record revealed fall prevention and fall recovery training last completed on July 29, 2024. E2's personnel record contained no additional evidence of continued competency training in fall prevention and fall recovery. 3. A review of E6's personnel record revealed fall prevention and fall recovery training last completed on May 2, 2024. E6's personnel record contained no additional evidence of continued competency training in fall prevention and fall recovery. 4. In an interview, E4 and E5 acknowledged the personnel files were missing initial training and continued competency training in fall prevention and fall recovery, and reported they would have each personnel member complete it. 5. In the exit interview, the findings were discussed with E4 and E5, and no additional comments or documentation were provided.

rule: R9-10-707.A.8.a. Admission; Assessment A. An administrator shall ensure that: 8. If a behavioral health assessment is conducted by a: a. Behavioral health technician or registered nurse, within 24 hours a behavioral health professional, certified or licensed to provide the behavioral health services needed by the resident, reviews and signs the behavioral health assessment to ensure that the behavioral health assessment identifies the behavioral health services needed by the resident; or

evidence: Based on record review and interview, the administrator failed to ensure if a behavioral health assessment was conducted by a behavioral health technician (BHT) or registered nurse, within 24 hours a behavioral health professional (BHP), certified or licensed to provide the behavioral health services needed by the resident, reviewed and signed the behavioral health assessment to ensure that the behavioral health assessment identified the behavioral health services needed by the resident. The deficient practice posed a risk as an analysis of the resident's needs for behavioral health services to determine which services a health care institution would provide was not completed.

findings: 1. A review of R2's medical record revealed a document titled, "Biopsychosocial Assessment Form," dated in June 2025. The document was signed and dated by the BHT who completed the assessment, but did not contain a signature or dated signed of the BHP who reviewed the document. 2. In an interview, E5 confirmed R2's behavioral health assessment was missing the signature of the behavioral health professional, and reported this was not a common practice for the facility. 3. In the exit interview, the findings were reviewed with E4 and E5 and no additional comments or documentation were provided.

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

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

findings: 1. A review of R2's medical record revealed a document titled, "Initial Treatment Plan," dated in June 2025. The document did not contain the signature of the BHP who reviewed the treatment plan. 2. In an interview, E5 confirmed R2's treatment plan was missing the signature of the BHP, and reported this was not a common practice for the facility. 3. In the exit interview, the findings were reviewed with E4 and E5 and no additional comments or documentation were provided.

rule: R9-10-722.B.8.k. Physical Plant Standards B. An administrator shall ensure that: 8. A resident bedroom complies with the following: k. Has a clothing rod or hook in the bedroom designed to minimize the opportunity for a resident to cause self-injury.

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

findings: 1. During a facility tour, the Compliance Officers observed three resident bedrooms containing four closet rod brackets that did not give way when downward pressure was applied. 2. A review of R1's medical record revealed a document titled, "Engagement Session Note," dated September 5, 2024, which stated, "[R1] has a history of threatening to commit suicide. R1] was hospitalized at [behavioral health hospital]...for suicidal ideations. [R1] had self-harmed. [R1] took a string about a week prior to the incident. and when [R1] became upset with a classmate [R1] had put the string around [R1's] neck. Then the following week, [R1] took a zip tie for a trash bag and wrapped it around [R1's] neck..." 3. In an interview, E5 reported to be unaware the closet rod brackets had the potential for a resident to cause self-injury, and confirmed they would be removed immediately. 4. In the exit interview, the findings were reviewed with E4 and E5 and no additional comments or documentation were provided.


summary: Compliance (Annual) - 7/23/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on July 23, 2024.

rule: C. An administrator shall ensure that: 3. Policies and procedures are reviewed at least once every three years and updated as needed;

evidence: Based on documentation review and interview, the administrator failed to ensure policies and procedures were reviewed and updated at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify the health care institution's standards.

findings: 1. A review of Department documentation revealed the facility's perpetual license was effective on September 20, 2019. 2. A review of facility documentation revealed a policy and procedure manual dated April 5, 2018. 3. A review of facility documentation revealed documentation to demonstrate the policies and procedures were reviewed and updated at least once every three years was not available for review. 4. In an interview, E2 reported the policies and procedures were always reviewed, but have not been updated. 5. In an interview, E2 acknowledged the the administrator failed to ensure policies and procedures were reviewed and updated at least once every three years.

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

evidence: Based on documentation review, and interview the administrator failed to ensure at least one personnel member present at the behavioral health facility during hours of operation had valid cardiopulmonary resuscitation (CPR) training. The deficient practice posed a health and safety risk to residents if facility staff were unable to ensure the health and safety of a resident during an emergency.

findings: 1. A review of E4's personnel record revealed documentation of CPR training. However, the CPR training card was through the NationalCPRfoundation, an online CPR training program dated January 7, 2024. 2. A review of the facilities personnel schedule for July 2024 revealed E4 worked alone on July 22, and July 23 from 10 pm to 8 am. 3. In an interview, E2 reported E2 was unaware the facility accepted online CPR training for E4. E2 acknowleged the administrator failed to ensure at least one personnel member present at the behavioral health facility during hours of operation had CPR training.

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: a. Is prepared at least one week in advance, b. Includes the foods to be served each day, c. Is conspicuously posted at least one calendar day before the first meal on the food menu will be served, d. Includes any food substitution no later than the morning of the day of meal service with a food substitution, and e. Is maintained for at least 60 calendar days after the last day included in the food menu;

evidence: Based on observation and interview, the registered dietician failed to ensure a food menu was prepared at least one week in advance, included the foods to be served each day and 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 as the Department was unable to determine the food served to the residents was in substantial compliance.

findings: 1. The Compliance Officer observed a menu conspicuously posted at the facility dated July 2024. The menu consisted of breakfast and snack. However, no additional menu's for dinner were provided for review. 2. In an interview, E2, stated E2 was unaware of what happened to the dinner menu. E2 acknowledged the registered dietician failed to ensure a food menu was prepared at least one week in advance, included the foods to be served each day and was conspicuously posted at least one calendar day before the fist meal on the food menu will be served.


summary: Compliance (Annual) - 8/8/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on August 8, 2023:

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 a personnel record was maintained for each personnel member to include documentation of the individual's license, for one of seven personnel records sampled.

findings: 1. A review of E4's personnel record revealed E4 was the facility's registered nurse. However, documentation of E4's nursing license was not available for review. 2. In an interview, E1 reported E4 had a nursing license, and was not sure why the nursing license was not in E4's personnel record. 3. In an interview, E1 acknowledged E1 failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's license.

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); 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 a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training, if required for the individual according to R9-10-703(C)(1)(e), and first aid training, for one of seven personnel members sampled. The deficient practice posed a risk if E3 was unable to meet a resident's needs during an emergency or an accident.

findings: 1. A review of facility documentation revealed a policy and procedure (dated March 2020) titled "First Aid, CPR, and prevention and support instruction." The policy stated "Employees will be notified prior to the expiration of their First Aid, CPR, or Prevention and Support training and will need to schedule time to attend the trainings annually." 2. A review of E1's personnel record revealed a CPR/First Aid card. However, the CPR/First Aid card expired August 1, 2023. 3. In an interview, E1 acknowledged E1 failed to ensure a personnel record was maintained for each personnel member to include documentation of CPR training and first aid training.

rule: A. Except for a behavioral health outdoor program, an administrator shall ensure that the premises and equipment are sufficient to accommodate: 2. An individual admitted as a resident by the behavioral health residential facility.

evidence: Based on observation, record review and interview, the administrator failed to ensure the premises was sufficient to accomodate an individual admitted as a resident by the behavioral health residential facility.

findings: 1. The Compliance Officer observed an opening in the facility's backyard wall which allowed unimpeded access into and out of the backyard. 2. A review of R2's medical record revealed a facility document titled "Pre-admission profile sheet." The document stated R2 "leaves house unauthorized." 3. In an interview, E1 acknowledged E1 failed to ensure the premises was sufficient to accomodate an individual admitted as a resident by the behavioral health residential facility.


summary: Compliance (Annual) - 11/25/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on November 25, 2025.


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

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

evidence: Based on record review, documentation review, and interview the administrator failed to ensure at least one personnel member present at the behavioral health facility during hours of operation had valid first-aid and cardiopulmonary resuscitation (CPR) training. The deficient practice posed a health and safety risk to residents if facility staff were unable to ensure the health and safety of a resident during an emergency.

findings: 1. A review of E5's personnel record revealed no documentation of cardiopulmonary and first aid training. A review of E5's personnel record revealed a document dated November 4, 2024, stating "The employment requirements you must submit are: First Aid/CPR... You have until 2/4/25 at 1:00 pm to submit the requirement(s)...." 2. A review of the facility staffing scheduled for November 2024, revealed E5 worked alone on November 15, 2024, from 2:00 PM to 9:00 PM and November 16, 2024, 9:00 AM to 9:00 PM. 3. In an interview, E1 reported E5 worked alone as identified on the personnel schedule.

rule: 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 developed and implemented for each resident and was reviewed and updated on an on-going basis according to the review date specified in the treatment plan. The deficient practice posed a health risk as a 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 dated August 23, 2023. The treatment plan identified a review date of "August 23, 2024." However, an updated treatment plan was not provided. 2. A review of R2's medical record revealed a treatment plan dated July 7, 2023. The treatment plan identified a review date of "July 7, 2024." However, an updated treatment plan was not provided. 3. In an interview, E1 reviewed R1 and R2's medical records. E1 acknowledged the identified treatment plans were the most current plans available for review.


summary: Complaint;Compliance (Annual) - 11/21/2023

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00193005 conducted on November 21, 2023:

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

evidence: Based on record review, documentation review, and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicted a self-injury or had an accident requiring immediate intervention by an emergency medical services provider. The deficient practice posed a risk as the Department was unable to determine if there was an immediate health and safety risk to other residents of the facility.

findings: 1. A review of R2's medical record revealed R2 had a history of suicidal ideation with a plan. A review of R2's medical record revealed a document titled "Incident Report" dated January 12, 2023. The report stated, "...While DSP was cleaning the kitchen, member went into the bathroom and locked the door. DSP immediately notified supervisor and called 911. While on the phone with dispatch DSP used the key to unlock the door. DSP found member sitting on the toilet seat with a sheet tied around [R2's] neck...Emergency responders evaluated member and transported to Banner Hospital." The document was signed by E3. 2. A review of facility documentation revealed no written notification to the Department of R2's self-injury, within two working days after R2 inflicted a self-injury or had an accident requiring immediate intervention by an emergency medical services provider. 3. In an interview, O1 acknowledged the Department was not provided written notification of R2's self-injury, within two working days after R2 inflicted a self-injury or had an accident requiring immediate intervention by an emergency medical services provider.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident's behavioral health issue and treatment needs were within the behavioral health residential facility's scope of services. The deficient practice posed a risk as a resident was admitted into a behavioral health residential facility who required a higher level of care.

findings: 1. A review of the facility policies and procedures revealed their scope of services. The scope of services stated, "...Behavioral Health Residential Services provides a structured treatment setting with twenty four hour supervision and counseling for individuals who do not require on site medical services..." 2. A review of R1's medical record revealed a behavioral health assessment dated January 9, 2023. R1's assessment identified the following information; "...Risk/Safety Suicidal Ideation: Current need area. Homicidal ideation: current need area. Safety/self-preservation skills: current needed area." 3. In an interview, O1 acknowledged the identified document was included in R1's admission documentation. O1 acknowledged the January 9, 2023, document identifies R1's current concerns of being a danger to self and others.

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment received from a behavioral health provider was completed within 12 months before the date of the resident's current admission and updated if additional information that affects the resident's assessment is identified, for one of three residents sampled. The deficient practice posed a risk as an analysis of the resident's needs for behavioral health services were not current.

findings: 1. A review of R1's medical record revealed two behavioral health assessments dated within twelve months prior to R1's admission dated December 14, 2022, and January 9, 2023. A review of R1's medical record revealed a behavioral health provider reviewed and updated R1's behavioral health assessment based on the December 14, 2022, assessment. A review of the January 9, 2023, assessment identified the following information; "...Risk/Safety Suicidal Ideation: Current need area. Homicidal ideation: current need area. Safety/self-preservation skills: current needed area." 2. In an interview, O1 reviewed R1's medical record. O1 acknowleged R1's medical record only included a review of the December 14, 2022, assessment. O1 acknowleged the January 9, 2023, was not identified in the behavioral assessment review. O1 acknowleged the behavioral health assessment did not identify additional information received that affected R1's assessment.

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

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

findings: 1. A review of R1's medical record revealed a document titled "Incident Report" dated February 5, 2023. The report stated "Another youth reported seeing R1 with a vape pen. Staff took the vape pen from youth and reported the incident to on call manager. DSP asked to give any other vape pens to DSP but [R1] stated [R1] did not have anymore..." 2. A review of R2's medical record revealed a document titled "Incident Report" dated January 12, 2023. The report stated "...While DSP was cleaning the kitchen member went into the bathroom and locked the door. DSP immediately notified supervisor and called 911. While on the phone with dispatch DSP used the key to unlock the door. DSP found member sitting on the toilet seat with a sheet tied around [R2's] neck...Emergency responders evaluated member and transported to Banner Hospital." The document was signed by E3. 3. In an interview, O1 reviewed the identified incident reports.O1 acknowleged the facility was licensed to provide behavioral health services to individual who behavioral health issues limit their ability to function independently. O1 acknowleged the incident reports revealed R1 and R2 were not provided continuous protective oversight.

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

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

findings: 1. A review of R1's medical record revealed a document titled "Incident Report" dated February 5, 2023. The report stated "Another youth reported seeing R1 with a vape pen. Staff took the vape pen from youth and reported the incident to on call manager. DSP asked to give any other vape pens to DSP but [R1] stated [R1] did not have anymore..." 2. In an interview, O1 reviewed the identified incident report. O1 acknowleged the incident report revealed R1 had access to a materials at the behavioral health residential facility that presented a threat to the minor residents health and safety.


facility_name: EAGLE'S NEST RESIDENTIAL - EUCLID

summary: Compliance (Annual) - 12/5/2025

raw_content: No deficiencies were found during the on-site compliance inspection conducted on December 5, 2025.


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

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


summary: Complaint - 9/26/2024

raw_content: An on-site investigation of complaint AZ00216461 was conducted on September 26, 2024 and the following deficiencies were cited:

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

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure that the licensed facility was free from a condition or situation that may cause a resident to suffer physical injury. The deficient practice posed a health and safety risk as the resident restrooms and bedrooms had a condition or situation that may cause a resident to suffer physical injury.

findings: 1. In a documentation review of the facility policy "Environmental Standards" last reviewed on August 9, 2024, it was revealed "...The premises will remain free from a condition or situation that may cause a resident or another individual to suffer physical injury...." 2. The Compliance Officer observed two grab bars in the shower of bathroom 1 and one grab bar in the shower of bathroom 2. All three grab bars were not anti-ligature, were securely installed and did not give way when downward pressure was applied. 3. The Compliance Officer observed two resident bedroom doors that were missing their locks, both creating ligature points. 4. In an interview, E1 acknowledged the grab bars and holes where the missing door locks were posed potential ligature hazards.


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

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on December 12, 2023:

rule: A. An administrator shall ensure that: 11. A behavioral health assessment: a. Documents a resident's: i. Presenting issue; ii. Substance abuse history; iii. Co-occurring disorder; iv. Legal history, including: (1) Custody, (2) Guardianship, and (3) Pending litigation; v. Criminal justice record; vi. Family history; vii. Behavioral health treatment history; viii. Symptoms reported by the resident; and ix. Referrals needed by the resident, if any;

evidence: Based on record review and interview, the administrator failed ensure a behavioral health assessment documented a resident's substance abuse history, co-occurring disorder, family history, and health treatment history, for one of two residents sampled.

findings: 1. A review of R1's medical record revealed a behavioral health assessment titled "Eagle's Nest Treatment Plan/Assessment" dated in May 2023. However, R1's behavioral health assessment did not include the following: -Substance abuse H\, -Co-occurring disorder, -Family history, and -Behavioral health treatment history 2. In an interview, E8 acknowledged R1's behavioral health assessment did not document all required components.

rule: C. An administrator shall ensure that: 2. Each counseling session is documented in a resident's medical record to include: c. Whether the counseling was individual counseling, family counseling, or group counseling;

evidence: Based on record review and interview, the administrator failed to ensure each counseling session was documented in the resident's medical record to include whether the counseling was individual counseling, family counseling, or group counseling, for two of two residents sampled.

findings: 1. A review of R1's medical record revealed a counseling note dated November 16, 2023. However, the counseling note did not indicate if the counseling was individual counseling, family counseling, or group counseling. 2. A review of R2's medical record revealed counseling note dated November 8, 2023. However, the counseling note did not indicate if the counseling was individual counseling, family counseling, or group counseling. 3. In an interview, E8 reported the aforementioned counseling was individual counseling provided by E4. E8 acknowledged the documentation of counseling sessions did not indicate they were individual counseling sessions. Technical assistance was provided on this Rule during the compliance inspection completed on December 19, 2022.

rule: B. An administrator shall ensure that: 2. At least one bathroom is accessible from a common area that: c. Contains the following: vii. A window that opens or another means of ventilation;

evidence: Based on observation and interview, the administrator failed to ensure at least one bathroom was accessible from a common area containing a window that opened or had another means of ventilation.

findings: 1. The Compliance Officer observed a hallway bathroom, accessible from a common area, contained an exhaust fan. However, the exhaust fan was not operable and the bathroom did not contain a window. 2. In an interview, E8 acknowledged the hallway bathroom did not contain a window or an operable exhaust fan. Technical assistance was provided on this Rule during the compliance inspection completed on December 19, 2022.


facility_name: ARIZONA CHILDREN'S GROUP LLC

summary: Compliance (Annual) - 2/23/2026

raw_content: The following deficiency was found during the attempted on-site compliance inspection conducted on February 23, 2026.

rule: R9-10-109.B.1-2. Changes Affecting a License B. If a licensee intends to terminate the operation of a health care institution , the licensee shall ensure that the Department is notified in writing of: 1. The termination of the health care institution's operations, as required in A.R.S. § 36-422(D), at least 30 calendar days before the termination, and 2. The address and contact information for the location where the health care institution ' s medical records will be retained as required in A.R.S. § 12-2297.

evidence: Based on documentation review and observation, the licensee failed to notify the Department in writing of the termination of the health care institution's operations at least 30 calendar days before the termination. The deficient practice posed a risk as the facility was not operating as a health care institution.

findings: A.R.S. § 36-401.23 "23. "Health care institution" means every place, institution, building or agency, whether organized for profit or not, that provides facilities with medical services, nursing services, behavioral health services, health screening services, other health-related services, supervisory care services, personal care services or directed care services and includes home health agencies as defined in section 36-151, outdoor behavioral health care programs and hospice service agencies." 1. A review of Department documentation revealed the license for BH5927 was effective on November 29, 2019, and was authorized to provide behavioral health services. 2. A review of Department documentation revealed a Compliance Officer attempted an on-site compliance inspection on February 20, 2025. However, complete acquiescence was not provided and the Compliance Officer observed what appeared to be a "For Sale" sign in the front yard. 3. A review of Department documentation revealed E1 sent a letter to the Department on February 20, 2025 reporting an emergency evacuation was made to BH10504 on January 18, 2025. However, BH10504 was an unlicensed facility and the application for licensure submitted on October 23, 2024 was denied on January 28, 2025. 4. A review of the Maricopa County Assessor website documentation revealed the residence sold to O1 and O2 on July 1, 2025 and is a primary residence. 5. The Compliance Officer arrived at the facility on February 23, 2026, at 9:37 AM and rang the doorbell and knocked on the front door and side door. However, no one answered either door. The Compliance Officer left a letter in the side door with instructions to call or email the Compliance Officer to confirm the operating status of a health care institution at the residence. An email was received from O1, which stated, "142 W Ivanhoe place Hello I received your letter about 142 w Ivanhoe place in Chandler and I just wanted to say No it is not operating as a health residential facility thank you."


summary: Compliance (Annual) - 2/20/2025

raw_content:
On July 7, 2023, the Department issued a Notice of Intent to Revoke for license BH5927. The Licensee, Arizona Children's Group LLC, and the Department entered into a Settlement Agreement to include any health care institution owned and/or operated by the licensee, with an execution date of October 13, 2023.

The following deficiency was found during the attempted on-site compliance inspection on February 20, 2025:

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 such action is deemed as a reasonable cause to believe a substantial violation under A.R.S. § 36-427(B) exists.

findings: 1. A review of Department documentation revealed the facility's perpetual license was effective on November 29, 2019. 2. The Compliance Officer arrived at the facility at 10:45 AM to conduct a compliance inspection. The Compliance Officer rang the door bell and knocked at the door. However, no one answered the door. 3.The Compliance Officer observed what appeared to be a for sale sign posted in the front yard. 4. In a telephonic interview, conducted at 10:51 AM, E1 reported the facility does not have any current residents and reported no one was on premises. E1 reported E1 could not meet the Compliance Officer as E1 was at an appointment. 5. The Compliance Officer called E1 again and left voicemail 10:58 AM and sent a text message at 11:10 AM. 6. The Compliance Officer did not receive a response from E1 and left the facility at 11:57 AM.


summary: Complaint;Compliance (Annual) - 1/11/2024

raw_content: On July 7, 2023, the Department issued a Notice of Intent to Revoke for license BH5927. The Licensee, Arizona Children's Group LLC, and the Department entered into a Settlement Agreement to include any health care institution owned and/or operated by the licensee, with an execution date of October 13, 2023. On January 11, 2024, the Department conducted an on-site compliance inspection and investigation of complaints AZ00201556, AZ00201558, and AZ00200268 for license BH5927 and found the licensee, Arizona Children's Group LLC, to be out of compliance with the following terms included in the agreement: -Term #8 "Pursuant to A.AC. R9-10-303, Licensee agrees to provide the Department with requested documents within two (2) hours of the request." -Term #10. "Licensee agrees to remain in substantial compliance with A.AC. Title 9, Chapter 10, Article 7." Per A.R.S. 36-401(46) "Substantial compliance" means that the nature or number of violations revealed by any type of inspection or investigation of a health care institution does not pose a direct risk to the life, health or safety of patients or residents. The licensee failed to meet the requirements of the Settlement Agreement for Term #8 and Term #10 as indicated in deficiencies cited in the compliance Statement of Deficiencies, Event ID: SOD NZV811.

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 health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Fall Prevention and Recovery Training for Caregivers" (date unavailable). However, the initial training and continued competency training requirement for all staff was not included in the policy. 2. In a joint interview, E1 and E2 acknowledged the policy did not include the initial training and continued training for all staff. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 3, 2023.

rule: B. An administrator: 3. Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the behavioral health residential facility's premises and accountable for the behavioral health residential facility when the administrator is not present on the behavioral health residential facility's premises.

evidence: Based on observation, record review, documentation review, and interview, the administrator failed to designate, in writing, an individual who was present on the behavioral health residential facility's premises and accountable for the behavioral health residential facility when the administrator was not present on the behavioral health residential facility's premises. The deficient practice posed a risk as E2 and E10 were not present on the premises and accountable when E1 was not present on the premises.

findings: 1. The Compliance Officer observed E3 working, alone, on the premises when the Compliance Officer arrived at approximately 11:20 AM. 2. A review of E3's (hired in 2023) personnel record revealed E3 was hired as a behavioral health technician (BHT/Peer Support). However, documentation designating E3 to be present on the behavioral health residential facility's premises and accountable for the behavioral health facility when the administrator was not present was not available for review. 3. The Compliance Officer observed E1 and E2 arrive on the premises at approximately 11:58 AM. 4. A review of the facility's policies and procedures revealed a policy titled "Administrator" (dated November 27, 2021). The policy stated "The Administrator may designates [sic] in writing, an individual who is present on the Arizona Children's Group Premises and accountable for the facility when the Administrator is not present and on-site...During the absence of the Administrator, a qualified designee will be the designated relief person who will assume the necessary Administrator responsibilities for the day-to-day operations of Arizona Children's Group in the interim...I [E10], accept the responsibility of Alternative Administrator for the agency on Monday-Friday, 8 a.m. to 5 p.m., in the absence of the above Administrator...I [E2], accept the responsibility of the secondary Alternative Administrator for the agency on Monday-Friday, 8 a.m. to 5 p.m., in the absence of the above primary Alternate Administrator..." The document was signed and dated in 2023, by E1, E2, and E10. 5. In a joint interview, E1 and E2 acknowledged E2 and E10 were not present on the behavioral health residential facility's premises and accountable for the behavioral health residential facility when E1 was not present on the behavioral health residential facility's premises. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 3, 2023.

rule: C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a resident that: a. Cover job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience for personnel members, employees, volunteers, and students;

evidence: Based on documentation review and interview, the administrator failed to establish and document policies and procedures to protect the health and safety of a resident to cover qualification, including skills and knowledge for personnel members, employees, volunteers, and students. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.

findings: 1. A review of Department documentation revealed the facility's perpetual license was effective on November 29, 2019. 2. A review of the facility's policies and procedures (dated November 27, 2021) revealed policies and procedures to include qualifications, including skills and knowledge were not available for review. 3. In a joint interview, E1 and E2 acknowledged policies and procedures were not established and documented to cover required skills and knowledge for personnel members, employees, volunteers, and students. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 3, 2023.

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

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

findings: 1. The Compliance Officer requested complete personnel records (per R9-10-706.G.1-3) for E1, E3, E4, E5, E6, E7, and E8 at 12:00 PM. 2. A review of E3's, E4's, and E6's personnel records revealed documentation of clinical oversight for the month of December 2023 was not available for review. 3. A review of documentation provided by E1, at approximately 6:00 PM, reveal clinical oversight for E3, E4, and E6. 4. A review of E7's (hired in 2023) personnel record revealed E7 was hired as the registered nurse. However, documentation of E7's completed orientation was not available for review. 5. A review of E8's (hired in 2023) personnel record revealed E8 was hired as the behavioral health professional. However, documentation of E8's completed orientation was not available for review. 6. In a joint interview, E1 and E2 acknowledged the requested documentation was not provided within two hours after a Department request. This is a repeat deficiency from the on-site compliance and complaint inspection conducted on March 3, 2023.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member completed orientation before providing behavioral health services, for two of eight personnel members sampled. The deficient practice posed a risk if E7 and E8 were unable to meet a residents needs.

findings: R9-10-101.153. "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 the facility's policies and procedures revealed a policy titled "Staff Qualifications, Training, and Responsibilities" (dated January 1, 2021). The policy stated "...When a community residential service is delivered...a direct care staff shall be present who has completed the following required training...Orientation to the specific needs of clients living in the community residential setting..." 2. A review of E7's (hired in 2023) personnel record revealed E7 was hired as the registered nurse. However, documentation of E7's completed orientation was not available for review. 3. A review of E8's (hired in 2023) personnel record revealed E8 was hired as the behavioral health professional. However, documentation of E8's completed orientation was not available for review. 4. In a joint interview, E1 and E2 acknowledged E7's and E8's orientation had not been completed prior to providing behavioral health services or physical health services.

rule: A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis: a. Before or within seven calendar days after the resident's admission, and b. As specified in R9-10-113.

evidence: Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's admission, for one of two current residents sampled. The deficient practice posed a TB exposure risk to residents.

findings: 1. A review of R2's (admitted in 2023) medical record revealed documentation a TB test had been administered (dated in October 2023). However, documentation of the TB test result and freedom from infectious TB was not available for review. 2. In a joint interview, E1 and E2 acknowledged R2 did not provide evidence of freedom from infectious TB before or within seven calendar days after R2's admission. This is a repeat deficiency from the on-site compliance and complaint investigation conducted on March 3, 2023.

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

evidence: Based on record review and interview, the administrator failed to ensure a treatment plan was developed for each resident to include the number of hours of counseling to be provided to the resident per R9-10-716(B)(2), for two of two current residents sampled and one of four discharged residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

findings: 1. A review of R1's medical record revealed a treatment plan (dated in December 2023). The treatment plan did include the frequency of counseling to be provided. However, the treatment plan did not include the number of hours of counseling to be provided to R1. 2. A review of R2's medical record revealed a treatment plan (dated in December 2023). The treatment plan did include the frequency of counseling to be provided. However, the treatment plan did not include the number of hours of counseling to be provided to R2. 3. A review of R4's medical record revealed a treatment plan (dated in September 2023). The treatment plan did include the frequency of counseling to be provided. However, the treatment plan did not include the number of hours of counseling to be provided to R4. 4. In a joint interview, E1 and E2 acknowledged R1's, R2's, and R4's treatment plans did not include the number of hours of counseling to be provided to R1, R2 and R4.

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

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

findings: 1. A review of R1's medical record revealed a treatment plan (dated in December 2023) developed by E8. However, the treatment plan did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 2. A review of R2's medical record revealed a treatment plan (dated in December 2023) developed by E8. However, the treatment plan did not include the signature of the resident's representative, and the date signed, or documentation of the refusal to sign. 3. In a joint interview, E1 and E2 acknowledged R1's and R2's treatment plans did not include the signature of the resident's representative, and date signed, or documentation of the refusal to sign.

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

evidence: Based on record review and interview, the administrator failed to ensure at the time of admission, a resident or the resident's representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (E), for two of two current residents sampled. The deficient practice posed a risk as individuals were not informed of the resident requirements and rights.

findings: 1. A review of R1's and R2's medical records revealed documented evidence of R1 and R2 receiving a written copy of the requirements in subsection (B) and the resident rights in subsection (E) were not available for review. 2. In a joint interview, E1 and E2 acknowledged the two residents or resident's representatives did not receive a written copy of the requirements in subsection (B) and the resident rights in subsection (E).


facility_name: ANGEL SAFE HAVEN LLC

summary: Complaint - 4/7/2026

raw_content: No deficiencies were found during the on-site investigation of complaint 00164831 conducted on April 7, 2026.