summary: Complaint - 10/3/2025

raw_content: The following deficiencies were found during the on-site investigation of complaint 00145870 conducted on October 3, 2025:

rule: R9-10-703.C.5.a-b. Administration 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 b. When documentation or information is required by this Chapter to be submitted on behalf of a behavioral health residential facility, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the behavioral health residential facility.

evidence: Based on documentation review, record review and interview, the administrator failed to ensure documentation required by this Article 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, and the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. The Compliance Officers arrived at the facility at 8:30 AM. 2. The Compliance Officers requested to review the daily staffing schedule (per R9-10-706.K.3.a.b.c.), two discharged residents' medical records (per R9-10-712.A.1), the facility's policies and procedures (per R9-10-703.C.1.2.), and four personnel records (per R9-10-706.H.1.a.b.). 3. The Compliance Officers were provided the daily staffing schedule, two discharged residents' medical records, the facility's policies and procedures, and two personnel records. However, E3's and E4's personnel records were not provided. 4. In an exit interview with E1, at 10:47 AM, E1 acknowledged E3's and E4's personnel records were not provided for review within two hours of the Department's request. E1 reported E1 did not have the key to the filing cabinet where E3's and E4's personnel records were stored. E1 reported E3 had the key to the cabinet and was on the way to the facility. However, E3 did not arrive to the facility prior to the Compliance Officers completing the exit interview with E1. This is a repeat violation from the on-site compliance inspection conducted on April 27, 2023 and the on-site complaint investigation conducted on June 4, 2023.

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

evidence: Based on observation and interview, the administrator failed to ensure the following information was conspicuously posted on the premises: the behavioral health residential facility's current license and the location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review.

findings: 1. The Compliance Officers observed a hallway upon entering the behavioral health facility. However, the hallway contained no conspicuous postings, as required in R9-10-720(C.) 2. The Compliance Officers observed a room with a sign on the door stating "office." The Compliance Officers were able to look into the office and observed a computer desk, chair, a plastic set of drawers and a daybed. 3. In an interview, E1 reported the "office" room was the privacy room. E1 reported the facility's license was posted in the privacy room. E1 reported the privacy room was typically locked and not accessible for residents unless visitors came to the facility. E1 acknowledged the facility's license and the requirements in R9-10-720(C) were not posted conspicuously. 4. In an exit interview, E1 acknowledged the facility's license and requirements in R9-10-720(C) were not posted conspicuously.

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

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

findings: 1. A review of E1's personnel record revealed a fingerprint clearance card. However, the fingerprint clearance card expired on July 22, 2025. 2. A review of the Department of Public Safety's website revealed E1's fingerprint clearance card was not valid. 3. In an exit interview, E1 acknowledged E1's fingerprint clearance card had expired, was not valid and had not been renewed. E1 reported E1 had applied for a new fingerprint clearance card, however, E1 could not provide the Compliance Officers with an application number, or a copy of the application. This is a repeat violation from the on-site complaint investigation conducted on June 17, 2025.

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 and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training, for one of two personnel records sampled. The deficient practice posed a risk if E2 was unable to meet a resident’s needs during an accident, emergency, or injury and the repeat violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. A review of E2's (hired in 2025) personnel record revealed a CPR card from NationalCPRFoundation, issued on June 23, 2025. However, the training was from an online program and did not include a demonstration. 2. In an exit interview, the findings were reviewed with E1 and no additional information or documentation were provided for review. This is a repeat violation from the on-site complaint investigation conducted on October 4, 2024.

rule: R9-10-706.H.1.a. Personnel H. An administrator shall ensure that personnel records are: 1. Maintained: a. Throughout an individual's period of providing services in or for the behavioral health residential facility, and

evidence: Based on documentation review, record review and interview, the administrator failed to ensure personnel records were maintained throughout an individual's period of providing services in or for the behavioral health residential facility. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

findings: 1. A review of facility documentation revealed a daily staffing schedule, titled "October 2025." The daily staffing schedule indicated E3 was scheduled to work Tuesdays, Wednesdays, Saturdays and Sundays at the facility, and indicated E4 was on-call for the facility. 2. The Compliance Officers requested to review E3's and E4's personnel records. However, no personnel records for E3 and E4 were provided. 3. In an exit interview, E1 reported E1 did not have the key to the filing cabinet where E3's and E4's personnel records were kept. E1 reported E3 had the key to the cabinet and was on the way to the facility. However, E3 did not arrive to the facility prior to the Compliance Officers completing the exit interview with E1.

rule: R9-10-706.J.1. Personnel 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 observation, documentation review, record review and interview, the administrator failed to ensure at least one personnel member was present at the behavioral health residential facility during hours of operation of the behavioral health residential facility who had cardiopulmonary resuscitation (CPT) training specific to the populations served, for one of two personnel records sampled. The deficient practice posed a risk if E2 was unable to meet a resident’s needs during an accident, emergency, or injury; and the repeated violation shows a pattern of non-compliance to ensure the health and safety of residents.

findings: 1. The Compliance Officers observed E2 working alone with one resident at the behavioral health facility at 8:30 AM. 2. A review of a daily staffing schedule, dated "September 2025" revealed E2 worked eighteen (18) shifts alone at the behavioral health facility. 3. A review of E2's (hired in 2025) personnel record revealed a CPR card from NationalCPRFoundation, issued on June 23, 2025. However, the training was from an online program and did not include a demonstration. 4. In an exit interview, the findings were reviewed with E1 and no additional information or documentation were provided for review. This is a repeat violation from the on-site complaint investigation conducted on October 4, 2025.

rule: R9-10-711.A.1. Resident Rights A. An administrator shall ensure that: 1. The requirements in subsection (B) and the resident rights in subsection (E) are conspicuously posted on the premises;

evidence: Based on observation and interview, the administrator failed to ensure the requirements in subsection (B) and the resident rights in subsection (E) were conspicuously posted on the premises. The deficient practice posed a risk if residents were unaware of the requirements and the resident rights.

findings: 1. The Compliance Officers observed a hallway upon entering the behavioral health facility. However, the hallway contained no conspicuous posted requirements in subsection (B) and the resident rights in subsection (E.) 2. The Compliance Officers observed a room with a sign on the door stating "office." The Compliance Officers were able to look into the office and observed a computer desk, chair, a plastic set of drawers and a daybed. However, the "office" did not contain conspicuously posted requirements in subsection (B) and the resident rights in subsection (E.) 3. In an exit interview, E1 reported the "office" room was the privacy room. E1 acknowledged the requirements in subsection (B) and the resident rights in subsection (E) were not conspicuously posted.

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

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

findings: 1. The Compliance Officers observed a wooden chair at the dining room table. The seat to the wooden chair was not fully secured to the chair and as the Compliance Officer attempted to sit on the chair, the seat spun around, exposing screws and sharp wooden pieces. 2. The Compliance Officers observed R3's bedroom. The bedroom contained a bathroom, in which the medicine cabinet contained a shaving razor and pair of scissors. 3. The Compliance Officers observed R3's bedroom closet. The closet contained three sets of vinyl-coated metal shelving. Each shelf had openings and were secured to the wall by brackets. Each shelf and bracket was weight-bearing and did not give when the Compliance Officer applied downward pressure. 4. The Compliance Officers observed R4's bedroom closet door was off the closet tracks and leaned again the closet/bedroom wall. 5. In an exit interview, the findings were discussed with E1 and no additional information or documentation were provided for review.

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

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

findings: 1. The Compliance Officers observed an unlocked privacy room. A can of Lysol Disinfectant Spray was on the desk. The can contained a toxic warning label. 2. The Compliance Officers observed an unlocked garage. The garage contained Gain detergent on a shelf above the washing machine. In the middle of the garage, on the ground were several 5-gallon jugs of pain, several pints of paint and several gallons of paint. To the left of the washing machine were two large containers of laundry detergent. The cans and containers contained toxic warning labels. 3. In an exit interview, the findings were reviewed with E1 and no additional information or documentation were provided for review.

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 and interview, the administrator failed to ensure a resident bedroom contained a clothing rod or hook designed to minimize the opportunity for a resident to cause self-injury. The deficient practice posed a ligature risk to residents.

findings: 1. The Compliance Officers observed R4's bedroom closet contained a J-hook bracket. The hook did not give way when the Compliance Officer applied downward pressure. 2. The Compliance Officers observed R5's bedroom closet contained a J-hook bracket. The hook did not give way when the Compliance Officer applied downward pressure. 3. In an exit interview, the findings were reviewed with E1 and no additional explanation or documentation were provided for review.


state: AZ

facility_name: SUNFLOWER LIVING LLC

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

raw_content: The following deficiencies were found during the on-site investigation of complaint 126141 conducted on June 17, 2025.

inspection_type: Complaint;Compliance (Annual)

evidence: Based on record review and interview, the administrator failed to ensure a personnel record was maintained to include documentation of Arizona Revised Statutes (A.R.S.) § 36-411(C)(1) and documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) § 36-425.03(E), for two of four personnel members sampled. The deficient practice posed a risk if E2 and E4 were a danger to a vulnerable population.

findings: A.R.S. § 36-425.03(A) states "Except as provided in subsections B, C and D of this section, children's behavioral health program personnel, including volunteers, shall submit the form prescribed in subsection E of this section to the employer and shall have a valid fingerprint clearance card issued pursuant to title 41, chapter 12, article 3.1 or, within seven working days after employment or beginning volunteer work, shall apply for a fingerprint clearance card." A.R.S. § 36-425.03(E) states "Children's behavioral health program personnel shall certify on forms that are provided by the department and notarized that they are not awaiting trial on or have never been convicted of or admitted in open court or pursuant to a plea agreement to committing any of the offenses listed in section 41-1758.03, subsection B or C in this state or similar offenses in another state or jurisdiction." A.R.S. § 36-411(C)(1) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency." 1. A review of E2's personnel record revealed documentation of compliance with A.R.S. § 36-411(C)(1) was not available for review. Additionally, E2’s personnel record revealed a valid fingerprint clearance card, however, documentation of compliance with A.R.S. § 36-425.03(E) was not available for review. 2. In an interview, E1 reported E2 worked at the facility previously, and has not worked at the facility for “awhile”. E1 reported E2 is currently employed. Additionally, E2 was scheduled to work at the facility later in the week. 3. A review of E4’s personnel record revealed a valid fingerprint clearance card, however, documentation of compliance with A.R.S. § 36-425.03(E) was not available for review. 4. In an exit interview, the findings were reviewed with E1, and further documentation or comment was not provided.

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

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

findings: A.R.S. § 8-804(K) states "Before being employed in a position that provides direct services to children or vulnerable adults pursuant to subsection B, paragraphs 4, 5 and 10 and 11 or subsections C and D and E of this section, employees shall certify, under penalty of perjury, on forms that are provided by the department whether an allegation of abuse or neglect was made against them and was substantiated. The forms are confidential. If this certification does not indicate a current investigation or a substantiated report of abuse or neglect, the employee may provide direct services pending the findings of the central registry check." 1. A review of E2's (hired in 2025) personnel record revealed E2 was a behavioral health technician. However, no documentation demonstrating the licensee submitted to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct a central registry background check on E2 was available for review. 2. A review of E4's (hired in 2025) personnel record revealed E4 was a behavioral health technician. However, no documentation demonstrating the licensee submitted to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct a central registry background check on E4 was available for review. 3. In an exit interview, the findings were reviewed with E1, and further documentation or comment were not provided.

rule: R9-10-706.G.3.j. 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: j. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (F).

evidence: Based on record review and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB), as specified in Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) and R9-10-113(A)(2) for two of four personnel sampled. The deficient practice posed a potential TB infection risk to residents.

findings: Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC). Arizona Administrative Code (A.A.C.) R9-10-113(A)(2) If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1). 1. A review of the CDC website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 2. A review of E2's personnel record (hired in 2025) revealed documentation of E2's freedom of infectious TB, per R9-10-113 (A)(2)(iii) of two-step testing, and documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB was not available for review. 3. A review of E4's personnel record (hired in 2025) revealed documentation of E4's freedom of infectious TB, per R9-10-113 (A)(2)(iii) of two-step testing, and documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB was not available for review. 4. In an exit interview, the findings were reviewed with E1, and further documentation or comment was not provided.

rule: R9-10-711.E.3.a. Resident Rights E. A resident has the following rights: 3. To receive privacy in treatment and care for personal needs, including the right not to be fingerprinted, photographed, or recorded without consent, except: a. A resident may be photographed when admitted to a behavioral health residential facility for identification and administrative purposes;

evidence: Based on observation and interview, the administrator failed to ensure a resident had the right to receive privacy in treatment and care for personal needs, including the right not to be fingerprinted, photographed, or recorded without consent. The deficient practice posed a risk if residents were unable to ensure their privacy.

findings: 1. The Compliance Officer observed cameras installed on the ceiling of two resident bedrooms and the living room area. The Compliance Officer observed the office television screen displaying the video feed from the bedrooms and the living room area. 2. A review of R1’s and R2’s medical records revealed no documentation of evidence to indicate R1 and R2 consented to being recorded or documentation from R1's and R2's representatives indicating the residents were not allowed to have privacy. 3. In an interview, E1 reported the cameras were in the bedroom for safety and security purposes, and the videos are maintained on a temporary basis. E1 reported the Department did not previously have an issue with the cameras in the bedrooms. During the inspection, E1 disconnected the cameras. 4. In an exit interview, the findings were reviewed with E1 and further comment was not provided.

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

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

findings: 1. The Compliance Officer observed three bedrooms in the facility occupied by five residents. However, all three bedrooms did not contain doors. 2. In an interview, E1 reported the bedroom doors had been removed for safety concerns. 3. In an exit interview, the findings were reviewed with E1 and further comment was not provided.


summary: Complaint - 11/18/2024

raw_content: An on-site investigation of complaint AZ00218681 was conducted on November 18, 2024 and no deficiencies were cited :

inspection_type: Complaint


summary: Complaint - 10/4/2024

raw_content: An on-site investigation of complaint AZ00216916 and AZ00216920 was conducted on October 4, 2024 and the following deficiencies were cited :

rule: B. An administrator shall ensure that: 3. Sufficient personnel members are present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to: a. Provide the services in the behavioral health residential facility's scope of services, b. Meet the needs of a resident, and c. Ensure the health and safety of a resident.

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

findings: 1. A review of facility documentation revealed the facility scope of services which stated "Resident Agency Status...Shift # 1...resident to personnel ratio - (3:1)...Shift # 2... resident to personnel ration - (3:1).... Shift # 3....resident to personnel ration - (3:1)..." 2. A review of facility documentation revealed daily staffing schedules from August-October 2024. The August 2024 daily staffing schedule revealed one personnel member was present on sixty-five out of seventy scheduled shifts. The September 2024 daily staffing schedule revealed one personnel member was present on seventy-one out of seventy-one scheduled shifts. The October 2024 daily staffing schedule revealed one personnel member was present on ten out of eleven scheduled shifts. 3. In an interview, E1 reported a current census of five residents. 4. A review of facility documentation revealed the facility scope of services which stated "Behavioral Health Technician Minimum qualifications: A high school diploma or school equivalency diploma (GED) and has 18 credit hours of post-high school education in a field related to behavioral health and two years full-time behavioral health experience." 5. A review of E2's (date of hire August 2024) personnel record revealed E2 was hired as a behavioral health technician. However, a combination of eighteen credit hours of post-high school education in a field related to behavioral health and two years full-time behavioral health experience was not available for review. 6. In an interview, E1 acknowledged there was not sufficient personnel present at the behavioral health residential facility's premises to provide the services in the behavioral health residential facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident. E1 acknowledged E2 was hired not meeting the education and experience requirements of a behavioral health technician.

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

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member which included documentation of cardiopulmonary resuscitation training, for one of two personnel records sampled. The deficient practice posed a health and safety risk as E2's cardiopulmonary resuscitation training did not include a skills evaluation.

findings: 1. A review of facility documentation revealed a policy and procedure titled "Personnel Members Requirements & Verification of Qualifications, Skills, and Knowledge." The policy stated "All personnel present at the facility during hours of operation and/or on an outing must have current documentation indicating successful completion of first aid and CPR, and the ability to perform CPR." 2. A review of E2's personnel record revealed E2's "American Red Cross Training Services Certificate of Completion." However, the certificate stated "[E2] has successfully completed requirements for Adult First Aid/CPR/AED Online (Eligible for Skills Session within 90 days)." 3. In an interview, E1 reported E2 had completed the skills session. E1 acknowledged E2's personnel record did not contain documentation of children's cardiopulmonary resuscitation training with a completed skills evaluation.

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

evidence: Based on documentation review, record review and interview, the administrator failed to ensure one personnel member who was present at the behavioral health residential facility during hours of operation had first-aid and cardiopulmonary resuscitation training specific to the populations served, for one of two personnel records sampled. The deficient practice posed a health and safety risk as E2's cardiopulmonary resuscitation training did not include a skills evaluation and was not specific to the population served.

findings: 1. A review of facility documentation revealed the scope of services which stated "Sun Flower Living, LLC is a twenty-four-hour Behavioral Health Residential facility for adolescent males ages 18 years or younger." 2. A review of facility documentation revealed a policy and procedure titled "Personnel Members Requirements & Verification of Qualifications, Skills, and Knowledge." The policy stated "All personnel present at the facility during hours of operation and/or on an outing must have current documentation indicating successful completion of first aid and CPR, and the ability to perform CPR." 3. A review of the facilities documentation revealed daily staffing schedules from August-October 2024. The daily staffing schedules reported E2 was the only personnel member present during E2's scheduled work hours on the following dates: - August: 18, 19, 20, 21, 22, 25, 26, 27, 28, 29. - September: 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 24, 25, 26, 30. - October: 1-3. 4. A review of E2's personnel record revealed E2's "American Red Cross Training Services Certificate of Completion." However, the certificate stated "[E2] has successfully completed requirements for Adult First Aid/CPR/AED Online (Eligible for Skills Session within 90 days)." However, documentation of E2's completed skills session was not available for review. 5. In an interview, E1 reported E2 had completed the skills session. E1 acknowledged E2's personnel record did not contain documentation of children's cardiopulmonary resuscitation training with a completed skills evaluation. E1 acknowledged E2 was left alone in the facility with residents without completed documentation of cardiopulmonary resuscitation training specific to the population served.

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

evidence: Based on record review and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a health risk to residents as R1's sleep was intentionally disturbed on a school night.

findings: 1. A review of R1's medical record revealed an incident report dated September 18th with a start time of 10:45 P.M. R1's incident report stated "Staff noticed before bedtime at 8pm that there was a flavorful smell coming from the hallway after [R1] came from the bathroom and cut the fan off inside of the bathroom. The smell that staff could smell was a strong smell of cherries and strawberries but staff noticed that [R1] did not have any perfume spray in [R1's] hands. Staff also noticed that [R1] had red eyes as well after leaving out of the bathroom right before bedtime. Staff waited around until 10:45pm when staff knew that CV would be sleeping for the night. Staff decided to search [R1's] bedroom with the help of 3 other staff members present to watch for any sudden moves made by [R1] as the search began at 10:45pm. Staff cut on the bedroom light and asked [R1] to wake up. One staff began to take the pillows and stuffed animals off the bed. Another staff took the extra blanket sitting on the foot of the bed off the bed, so that all staff could see the bed in its entirety. [R1] was sleeping on top of the comfortor [sic] and did not have any cover on for staff to remove. Staff then asked [R1] to get out of the bed biut [sic] [R1] refused and said [R1] does not want t oget [sic] out of the bed. Staff asked repeatedly for [R1] to get out of the bed so that staff can search [R1's] room and so that staff can have [R1] empty [R1's] pockets. As [R1] was refusing to get out of the bed, one other staff member was searching [R1's] dresser drawers and [R1's] closet as well. Staff informed [R1] that staff believes [R1] has a vape and would like for [R1] to give it up. [R1] stated that [R1] does not have anything and stated that [R1] is just tired. Staff then again asked [R1] to get out of bed and [R1] refused. Staff informed [R1] that no one will be physically touching [R1] or searching [R1] and let [R1] know that all [R1] has to do is stand up and empty out [R1's] pockets and let staff continue to search the entire room. Staff informed [R1] that if [R1] continues to refuse to get out of the bed, then the police will be called to the home to help with the search. Staff let [R1] know that if the police find [R1] in possession of an illegal substance for [R1's] age, they made decide to take [R1] to jail tonight. After 2 minutes passed, [R1] then stated, "here, just take it" and handed staff a Vape that has liquid marijuana present inside of it." 2. In an interview, the Compliance Officer asked E1 why personnel waited for R1 to fall asleep before conducting the room search, knowing R1 had school the next morning. E1 reported staff waited for R1 to fall asleep to catch R1 off guard and to prevent R1 from reacting to the search. The Compliance Officer asked if R1 could have been "caught off guard" after R1 exited the bathroom or at any point prior to R1 going to bed to which E1 stated "yes, R1 could have." E1 acknowledged waiting for R1 to fall asleep, on a school night, to catch R1 off guard for a room search was not treating R1 with dignity, respect or consideration.


summary: Complaint - 9/18/2024

raw_content: An on-site investigation of complaint AZ00216180 was conducted on September 18, 2024 and the following deficiencies were cited :

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

evidence: Based on record review and interview, the administrator failed to report suspected abuse, neglect, or exploitation of a resident under 18 years of age according to A.R.S. \'a7 13-3620. The deficient practice posed a risk as the facility did not immediately report to the department of child safety (DCS) or a peace officer when a resident informed the facility of suspected abuse, neglect, or exploitation, as DCS or a peace officer were unable to assess if there was an immediate health and safety concern for the resident and other residents residing in the behavioral health residential facility.

findings: A. Any person who reasonably believes that a minor is or has been the victim of physical injury, abuse, child abuse, a reportable offense or neglect that appears to have been inflicted on the minor by other than accidental means or that is not explained by the available medical history as being accidental in nature or who reasonably believes there has been a denial or deprivation of necessary medical treatment or surgical care or nourishment with the intent to cause or allow the death of an infant who is protected under section 36-2281 shall immediately report or cause reports to be made of this information to a peace officer, to the department of child safety or to a tribal law enforcement or social services agency for any Indian minor who resides on an Indian reservation, except if the report concerns a person who does not have care, custody or control of the minor, the report shall be made to a peace officer only. A member of the clergy, a Christian Science practitioner or a priest who has received a confidential communication or a confession in that person's role as a member of the clergy, as a Christian Science practitioner or as a priest in the course of the discipline enjoined by the church to which the member of the clergy, the Christian Science practitioner or the priest belongs may withhold reporting of the communication or confession if the member of the clergy, the Christian Science practitioner or the priest determines that it is reasonable and necessary within the concepts of the religion. This exemption applies only to the communication or confession and not to personal observations the member of the clergy, the Christian Science practitioner or the priest may otherwise make of the minor. For the purposes of this subsection, "person" means... R9-10-101.110 states "Immediate" means without delay. 1. A review of R1's medical record revealed an incident report dated July 13, 2024. R1's incident report documented a sexual altercation between R1 and an unknown individual which took place in the family restroom at the Peoria Recreation Center, during a facility outing. The incident report reported R1 stated R1 used the family restroom, while personnel was busy with another resident, knowing personnel would not have the ability to enter the locked restroom. The incident report stated R1 engaged in oral sex and was then paid $20. Further review of R1's medical record revealed a document titled "AWOL Plan & Protocol." The document stated in the left-hand corner "Incident reported 7/12 admitted 7/13." The document further stated "Date: 7/17/24 Time: 8:00 P.M. Name: [R1] ...Call Non-emergency Police Hotline ... a. name of person talked to Report #..... 2. Call DCS Hotline a. Name of person talked to [O1]...7/17/24 10:40 AM ..." 2. In an interview, E1 reported R2 reported the incident to personnel and R1 originally denied the altercation. R1 then admitted to the altercation and an incident report was documented on July 13, 2024. E1 reported R1 was unaware of what day the altercation took place. E1 reported the incident report was provided to the guardian and case management team on July 13, 2024. However, E1 reported E1 was unaware the facility had to notify DCS or a peace officer in the event of potential abuse, neglect or exploitation. E1 reported while a meeting was taking place with R1's case management team and guardian, R1's guardian suggested reporting the altercation to DCS and a peace officer to protect the facility. E1 acknowledged the requirement to notify DCS or a peace officer immediately after suspecting potential abuse, neglect or exploitation of a resident. E1 acknowledged four days after the incident was reported did not qualify as immediately reporting.

rule: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while a resident is receiving services from a behavioral health residential facility's employee or personnel member, the administrator shall: 5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in (I)(2): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition; c. The names of witnesses to the suspected abuse, neglect, or exploitation; and d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future;

evidence: Based on record review and interview, the administrator failed to ensure, if an administrator had a reasonable basis, according to A.R.S. \'a7 13-3620 or 46-454, to believe abuse had occurred on the premises or while a resident was receiving services from a behavioral health residential facility's employee or personnel member, the administrator initiated an investigation of the suspected abuse and documented: the dates, times, and description of the suspected abuse; a description of any injury related to the suspected abuse and any change to the resident's physical, cognitive, functional, or emotional condition; the names of the witness to the suspected abuse; and the actions taken by the administrator to prevent the suspected abuse from occurring in the future. The deficient practice posed a health and safety risk to residents.

findings: 1. A review of R1's medical record revealed an incident report dated July 13, 2024. R1's incident report documented a sexual altercation between R1 and an unknown individual which took place in the family restroom at the Peoria Recreation Center, during a facility outing. The incident report reported R1 stated R1 used the family restroom, while personnel was busy with another resident, knowing personnel would not have the ability to enter the locked restroom. The incident report stated R1 engaged in oral sex and was then paid $20. Further review of R1's medical record revealed a document titled "AWOL Plan & Protocol." The document stated in the left-hand corner "Incident reported 7/12 admitted 7/13." The document further stated "Date: 7/17/24 Time: 8:00 P.M. Name: [R1] ...Call Non-emergency Police Hotline ... a. name of person talked to Report #..... 2. Call DCS Hotline a. Name of person talked to [O1]... 7/17/24 10:40 AM ..." 2. In an interview, E1 reported an investigation had been conducted. E1 reported each resident was interviewed separately regarding the altercation and tried to narrow down what date the altercation took place. E1 reported E1 visited the Peoria Recreation Center to try and obtain camera footage to see what day the altercation happened and who the other individual was. E1 reported E1 was unable to determine the day of the altercation and could not place which personnel member was the one on the outing. E1 reported personnel stopped taking residents to the Peoria Recreation Center after becoming aware of the altercation to further prevent any potential abuse, neglect or exploitation. E1 could not provide any of the aforementioned information documented. E1 reported E1 was unaware the aforementioned information needed to be documented and maintained for twelve months.

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 a behavioral health residential facility 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 interpedently received continuous protective oversight. The deficient practice posed a health and safety risk as a child was potentially abused, neglected, or exploited while personnel should have been providing continuous protective oversight.

findings: 1. A review of facility documentation revealed the facility Scope of Services. The scope stated "Resident Agency Status ...During outings - 3 residents to 2 personnel members." 2. A review of facility documentation revealed a policy and procedure, review date unknown, titled "Excursions outside of the facility." The policy stated "B. Outing Plan will include 1. Minimum of 2 personnel members present to ensure each resident's safety, and welfare on an outing." 3. A review of R1's medical record revealed an incident report dated July 13, 2024. R1's incident report documented a sexual altercation between R1 and an unknown individual which took place in the family restroom at the Peoria Recreation Center, during a facility outing. The incident report reported R1 stated R1 used the family restroom, while personnel was busy with another resident, knowing personnel would not have the ability to enter the locked restroom. The incident report stated R1 engaged in oral sex and was then paid $20. 4. In an interview, E1 reported there were three residents admitted into the behavioral health residential facility at the time of the altercation. E1 reported one personnel member accompanied all three residents on a facility outing to the recreation center. E1 reported the recreation center had personnel members, sign in sheets, sign out sheets, and security to help provide continuous protective oversight. E1 acknowledged the recreation center was not responsible for providing continuous protective oversight and personnel members from the recreation center are not personnel members of the behavioral health residential facility. E1 acknowledged each resident was required continuous protective oversight, at all times. E1 acknowledged the facility was not in compliance with the scope of services or outings policy and procedure as both policies required a minimum of two personnel members to accompany residents on an outing. E1 acknowledged if personnel members had maintained continuous protective oversight, R1 potentially would not have had the ability to enter the family restroom with a male without being noticed.


summary: Complaint;Compliance (Annual) - 5/14/2024

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00204727 conducted on May 14, 2024:

rule: An administrator shall ensure that: 2. Documentation of current contracted services is maintained that includes a description of the contracted services provided.

evidence: Based on record review and interview, the administrator failed to ensure documentation of current contracted services included a description of the contracted services provided, for two of two contracted personnel members sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance for the facility's contracted staff.

findings: 1. A review of E5's personnel record revealed E5 was contracted as the facility's behavioral health professional (BHP). However, the contract maintained did not indicate E5 was available on-call. 2. In an interview, E1 reported E5 was the facility's BHP and was available on-call. E1 acknowledged the facility's contract with E5 did not include a description of on-call contracted services provided by E5. 3. A review of E6's personnel record revealed E6 was contracted by the facility as a registered dietitian (RD). E6's personnel record revealed a contract which stated, "This agreement is valid from March 1, 2024 through February 28, 2025. However, the contract was not signed and executed by either party. 4. In an interview, E1 reported E6 continued to provide RD services for the facility as specified in the contract. E1 reported E1 recently followed up over email to obtain a signed copy of the contract. E1 acknowledged documentation of current contracted services with E6 was not maintained.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of the individual's completed orientation as required by policies and procedures, for one of six personnel members sampled.

findings: 1. Arizona Administrative Code (A.A.C.) R9-10-101.153. states "Orientation" means: "the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution." 2. A review of facility policies and procedures revealed a policy titled "Staff Training" which stated, "Direct care staff will receive initial orientation ...All training will be documented. Copies of documentation will be retained in the employee record." 3. A review of R1's and R2 ' s medical records revealed counseling notes from group and individual counseling sessions conducted at BH7288 in March, April, and May of 2024. 4. A review of E4's personnel record revealed documentation of E4's completed orientation was not available for review. 5. In an interview, E1 reported E4 worked with E6. E1 reported E4 came on site to provide residents with counseling two times per week. E1 reported E4 did receive orientation specific to the facility, but E1 acknowledged E4 ' s personnel record was not maintained to include documentation of E4 ' s completed orientation.

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: g. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;

evidence: Based on record review and interview, the administrator failed to ensure a personnel record included documentation of clinical oversight, as required in Arizona Administrative Code (A.A.C.) R9-10-115, for one of four behavioral health technicians (BHT's) sampled. The deficient practice posed a risk to the health and safety of residents if clinical oversight was not provided to ensure a resident's needs were met.

findings: 1. A.A.C. R9-10-115.4. states: "A behavioral health technician receives clinical oversight at least once during each two-week period, if the behavioral health technician provides services related to patient care at the health care institution during the two-week period." 2. A review of R1's medical record revealed E4 provided individual counseling to R1 on March 11, 20, and 28; April 3, 8, 17, 25, and 29; and May 5 of 2024. 3. A review of E4's personnel record revealed E4 had a masters of science (MS) in professional counseling. However, E4 ' s record indicated E4 was not a licensed behavioral health professional (BHP) and acted as a behavioral health technician (BHT) counselor for the facility. E4 ' s personnel record revealed no documentation of clinical oversight. 4. In an interview, E1 reported E4 worked with E5 and received clinical oversight from E5 every week. E1 reported E1 was not aware the facility needed to maintain documentation of E4 ' s clinical oversight. E1 acknowledged E4's personnel record did not include documentation which indicated clinical oversight was provided for each two week period during which E4 provided counseling services.

rule: A. An administrator shall ensure that: 3. Except as provided in subsection (A)(4), general consent is obtained from: a. An adult resident or the resident's representative before or at the time of admission, or b. A resident's representative, if the resident is not an adult;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure that general consent was obtained from a resident's representative, for two of two residents sampled. The deficient practice posed a risk if a resident's representative consent for an adolescent resident to receive treatment at the facility.

findings: 1. Arizona Administrative Code (A.A.C.) R9-10-707(A)(3)(b) states: "A. An administrator shall ensure that: 3. Except as provided in subsection (A)(4), general consent is obtained from: b. A resident's representative, if the resident is not an adult." 2. A review of R1's medical record revealed documentation of general consent obtained in subsection (A)(3) was not available for review. 3. A review of R2's medical record revealed documentation of general consent obtained in subsection (A)(3) was not available for review. 4. In an interview, E1 reported to be unaware of the requirement. E1 acknowledged general consent for R1 and R2 was not obtained or documented in R1's and R2's medical records.

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 if residents and representatives were unaware of the requirements and the resident rights.

findings: 1. A review of R1's medical record revealed documented evidence to indicate R1's representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (E) was not available for review. 2.A review of R1's medical record revealed documented evidence to indicate R2's representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (E) was not available for review. 3. In an interview, E1 acknowledged documented evidence to indicate R1 and R2 or their representatives received a written copy of the requirements in subsection (B) and the resident rights in subsection (E) was not available for review.

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

evidence: Based on record review and interview, the administrator failed to ensure counseling was provided according to the frequency and number of hours identified in the resident's treatment plan, for one of two residents sampled.

findings: 1. A review of R1's medical record revealed a treatment plan dated February 13, 2024. The treatment plan stated, "Treatment Methods: Counseling ...Group 1x a week." The treatment plan did not identify the number of hours which counseling was to be provided. 2. A review of R1's medical record revealed documentation which indicated R1 received group counseling on April 7 and April 20, 2024. No documentation to indicate R1 received group counseling according to the frequency identified in R1's treatment plan in April and May of 2024 was not available for review. 3. In an interview, E1 reported R1 was preparing to discharge from the facility and did not attend some weekly counseling groups in April and May, 2024 as R1 was away from the facility for day visits with family. E1 acknowledged counseling was not provided according to the frequency identified in R1 ' s treatment plan.


summary: Complaint - 10/11/2023

raw_content: An on-site investigation of complaint AZ00201572 was conducted on October 11, 2023 and the following deficiencies were cited :

rule: G. An administrator shall provide written notification to the Department of a resident's: 1. Death, if the resident's death is required to be reported according to A.R.S. § 11-593, within one working day after the resident's death; and

evidence: Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. \'a7 11-593, within one working day after the resident's death. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for the other residents residing in the assisted living facility.

findings: 1. A review of facility documentation revealed an incident report dated September 24, 2023. The report stated "[R1] yelled that [R1] is leaving and is not coming back and stated [expletive] this place as [R1] ran off. Staff attempted to find [R1] and went around the neighborhood for about 20 minutes before calling the police non-emergency number to report the incident. Police have been alerted and have been provided information on [R1]..." 2. A review of facility documentation revealed e-mail correspondence between O1 and E1. The e-mail from O1 was dated September 27, 2023 and stated "I received a call from Durango Detention and they informed me a medical examiner [O2] called them and they identified a youth that has an ankle monitor that has been deceased...I asked if [O3] knows what happen and [O3] stated early in the morning, a witness stated [R1] was seen smoking a unknown substance at a QT off [street name] and [R1] was taken to the emergency room where [R1] died of a drug overdose..." 3. A review of Department documentation revealed the administrator failed to provide written notification to the Department of R1's death. 4. In an interview, E1 acknowledged E1 did not provide written notification to the Department of a resident's death within one working day after the resident's death.

rule: 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 a behavioral health assessment conducted by a behavioral health technician (BHT) or registered nurse (RN) was reviewed and signed by a behavioral health professional (BHP) within 24 hours, for two of two residents sampled. The deficient practice posed a risk as an analysis of the resident's needs for behavioral health services was not reviewed within 24 hours to ensure the behavioral health assessment identified the behavioral health services needed by the resident.

findings: 1. A review of R1's medical record revealed a behavioral health assessment signed and dated by E2, a BHT, on August 24, 2023. However, the assessment was not signed and dated by E4, the facility's BHP. 2. A review of R2's medical record revealed a behavioral health assessment signed and dated by E2, a BHT, on July 28, 2023. However, the assessment was not signed and dated by E4, the facility's BHP. 3. In an interview, E1 acknowledged the BHP did not review and sign the behavioral health assessments for R1 and R2 within 24 hours to ensure the behavioral health assessments identified the behavioral health services needed by the residents.


summary: Complaint - 6/14/2023

raw_content: An on-site investigation of complaint AZ00196514 was conducted on June 14, 2023 and the following deficiencies were cited :

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 documentation review and interview, the administrator failed to ensure documentation required by this Article 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. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? [R3] was suspected to have been smoking vape or marijuana and when confronted [R3] became irate and belligerent. [R3] ultimately left home with other peers and did not return. Special Incidents The individual is missing and the vendor has filed a missing persons report with a law enforcement agency...Review of incident, actions taken, and/or recommended...[R3] was questioned about eyes being red and why [R3's] responses were delayed after being outside with peers. [R3] stated that writer was "tweaking" and [R3] accused writer of being high because smoking was being questioned. [R3] denied having any vapes or substances [R3] offered for writer to check [R3's] pockets. [R3] was encouraged to go to be [sic] after dinner and informed of next days schedule. [R3's] peer appeared to be the provider of whatever that had been smoked...[R3's] peer suggested leaving because of [unknown] fear of in trouble with probation and potentially taken back to detention. [R3] was agreeable and immediately packed up a small bag and put shoes on. [R3] appeared to be more of a follower. [R3] left home with 3 other peers at about 915 pm. Staff came in to assisted and walked neighborhood and drove around to nearby stores and gas stations and [unknown] did not see them. A police report was filed..." Additionally, the document contained boxes which stated "Notifications...DES Case Worker...Parent/Guardian/TSS Case Worker." However, the boxes were not marked, and documentation of notification of R3's unauthorized absence to R3's parent or legal guardian was not available for review. 2. The Compliance Officer requested to review the facility's quality management program per Arizona Administrative Code (A.A.C.) R9-10-704. However, a documented quality management program per A.A.C. R9-10-704 was not available for review. 3. The Compliance Officer requested to review the facility's report required in A.A.C. R9-10-704(2) and the supporting documentation for the report. However, the report required in A.A.C. R9-10-704(2) and the supporting documentation for the report was not provided for review. 4. In an interview, E1 acknowledged the aforementioned documentation required by this Article was not provided to the Department within two hours after a Department request. This is a repeat citation from the on-site compliance inspection conducted on April 27, 2023.

rule: K. An administrator shall: 7. If a resident's absence is unauthorized as determined according to the criteria in subsection (K)(6), within an hour after determining that the resident's absence is unauthorized, notify: a. For a resident who is under 18 years of age, the resident's parent or legal guardian; and b. For a resident who is under a court's jurisdiction, the appropriate court;

evidence: Based on documentation review and interview, the administrator failed to ensure within an hour after determining a resident's absence was unauthorized according to the criteria in subsection (K)(6), the administrator documented the notification of resident's parent or legal guardian, for one discharged resident. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? [R3] was suspected to have been smoking vape or marijuana and when confronted [R3] became irate and belligerent. [R3] ultimately left home with other peers and did not return. Special Incidents The individual is missing and the vendor has filed a missing persons report with a law enforcement agency...Review of incident, actions taken, and/or recommended...[R3] was questioned about eyes being red and why [R3's] responses were delayed after being outside with peers. [R3] stated that writer was "tweaking" and [R3] accused writer of being high because smoking was being questioned. [R3] denied having any vapes or substances [R3] offered for writer to check [R3's] pockets. [R3] was encouraged to go to be [sic] after dinner and informed of next days schedule. [R3's] peer appeared to be the provider of whatever that had been smoked...[R3's] peer suggested leaving because of [unknown] fear of in trouble with probation and potentially taken back to detention. [R3] was agreeable and immediately packed up a small bag and put shoes on. [R3] appeared to be more of a follower. [R3] left home with 3 other peers at about 915 pm. Staff came in to assisted and walked neighborhood and drove around to nearby stores and gas stations and [unknown] did not see them. A police report was filed..." Additionally, the document contained boxes which stated "Notifications...DES Case Worker...Parent/Guardian/TSS Case Worker." However, the boxes were not marked, and documentation of notification of R3's unauthorized absence to R3's parent or legal guardian was not available for review. 2. In an interview, E1 reported R3's legal guardian is the Department of Child Safety (DCS). E1 reported E1 did notify R3's legal guardian, and acknowledged documentation of notification of R3's unauthorized absence to R3's legal guardian was not available for review.

rule: K. An administrator shall: 9. Evaluate and take action related to unauthorized absences under the quality management program in R9-10-704.

evidence: Based on documentation review and interview, the administrator failed to evaluate and take action related to unauthorized absences under the quality management program in Arizona Adminsitrative Code (A.A.C.) R9-10-704. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. A review of the facility's policies and procedures revealed an undated policy titled "QUALITY ASSURANCE POLICY". The policy stated "Sunflower Living LLC will:...i) Provide information and choices which will lead to a healthier lifestyle j) monitor and review the care provided at least annually or more frequently as required to meet the needs of the service user k) Identify, monitor, and manage risk to service users m) Audit communication logs, MAR sheets, falls, medication errors, absences, compliments & complaints." 2. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? Writer suspected that group of teens had been smoking and when teens were confronted [R1] became paranoid admitted guilt and encouraged group of peers to leave facility to avoid getting in trouble. Special Incidents The individual is missing and the vendor has filed a missing persons report with a law enforcement agency. Notifications Police DES caseworker...Review of incident, actions taken, and/or recommended...[R1] was outside with peer's before dinner and asked to come in and get cleaned up to eat. [R1] sat on couch and as writer began to serve pizza it was noted that [R1] was wearing dark shades...following dinner writer noticed [R1's] apprehension to remove glasses. Writer investigated situation. It look as if all 3 teens, [R3] [age], [R4] [age] and [R1] [age] was potentially high with red eyes and delayed responses. Writer questioned if they had been smoking. [R1] and peers denied...Writer asked again to be honest and give up smoke stick if [R1] had one. [R1] pulled [R1's] pockets inside out and a lighter was exposed. Writer asked about the need for a lighter and [R1] responded that 'it's mine, everyone has lighters." [R1] was informed that a drug test would be conducted for the 3 and that they should all go to bed. This made [R1] very paranoid. [R1] asked the writer not to share information with [R1's] team. [R1] asked that writer not call the police...[R1] stated that [R1] may as well as leave because [R1] refuses to go to jail for a smoking violation. [R1] proceeded to [R1's] room as [R1's] peers followed [R1's] lead...[R1] said [R1] would detox before any test, then [R1] admitted to smoking marijuana and asked that it not be exposed. Writer reminded [R1] that [R1] has a standing order to be tested bi weekly and it would be exposed. [R1] left officer and 5 mins later [R1] and [R1's] peers [R3], [R4], and [R2]...lined up at front door to exit home. Writer reminded all of them that they were only making matters worse and the safest most responsible thing to do was to go to bed and get a fresh start tomorrow...Writer explained that the only [sic] for a police to be called out was for [R1] continuing to disrupt home and the encouragement of involving others. [R1] was reminded that [R1] has been caught 3x with vapes in home and all were removed from [R1's] person. [R1] stated [R1] felt bad doing those things and all 4 kids walked out of the home. Police was notified and report was filed...Incident started at about 715 pm during dinner. [R1] left home around 915pm. Staff [E3] rode around neighborhood and also was outside by feet and did not locate [R1] or peers." 3. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? Peers decided to AWOL and [R2] decided [R2] was going with them. [R2] left home at 915 pm. At 3 am [R2] was found asleep in driveway. Special Incidents The individual is missing and the vendor has filed a missing persons report with a law enforcement agency. Notifications Police DES caseworker...Review of incident, actions taken, and/or recommended...At 9:15 pm writer found [R2] standing at front door with peers preparing to AWOL. Jesse was told by writer to remove [R2] and to go back to bed and [R2] shook [R2's] head and said "NO" As [R2's] peers began to walk out the door same [sic] with bags in the hand, [R2] walked out as well, empty handed and without shoes on. Staff [E3] came in and drove around neighborhood as well search outside home and [R2] nor [R2's] peers were found. Police was called and report was obtained. [R2] along with another peer was found to be outside asleep at about 3am. They were assisted back into home and went to bed." 4. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? [R3] was suspected to have been smoking vape or marijuana and when confronted [R3] became irate and belligerent. [R3] ultimately left home with other peers and did not return. Special Incidents The individual is missing and the vendor has filed a missing persons report with a law enforcement agency...Review of incident, actions taken, and/or recommended...[R3] was questioned about eyes being red and why [R3's] responses were delayed after being outside with peers. [R3] stated that writer was "tweaking" and [R3] accused writer of being high because smoking was being questioned. [R3] denied having any vapes or substances [R3] offered for writer to check [R3's] pockets. [R3] was encouraged to go to be [sic] after dinner and informed of next days schedule. [R3's] peer appeared to be the provider of whatever that had been smoked...[R3's] peer suggested leaving because of [unknown] fear of in trouble with probation and potentially taken back to detention. [R3] was agreeable and immediately packed up a small bag and put shoes on. [R3] appeared to be more of a follower. [R3] left home with 3 other peers at about 915 pm. Staff came in to assisted and walked neighborhood and drove around to nearby stores and gas stations and [unknown] did not see them. A police report was filed..." 5. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? [R4] followed group of teens in smoking marijuana and when group of teens planned to leave facility [R4] left facility as well. [R4] returned 7 hours later. Notifications Police case...Review of incident, actions taken, and/or recommended...[R4] has been hanging with...peer in home. [R4] seemed to be influenced to engage in smoking as writer found [R4] with red eyes and delayed responses. [R4] was questioned about [R4's] eyes being red and [R4] denied having involvement with smoking or drugs and also placed a bet that if [R4] was tested [R4] would pass and joked that when is is [sic] negative writer should give [R4] 10 dollars. However, [R4's] peers were more vocal and admitted to smoking. [R4's] peers were very paranoid and verbalized wanting to leave the facility to avoid getting in trouble. [R4] was encouraged not to worry about the events that took place and to go to bed and rest...After 10 minutes of [R4] talking with [R4's] peers writer found [R4] at the front door behind 2 others with bags packed preparing to leave the facility. [R4] left home with peers at about 915 pm. Staff [E3] came in to assist writer by driving the neighborhood as well as walked the streets and did not see [R4] or 3 others. Police report was filed after they did not return...At 3 am [R4] was found in the backyard asleep on the trampoline. [R4] came into home and went to bed." 6. The Compliance Officer requested

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

evidence: Based on documentation review and interview, the administrator failed to ensure the report required in subsection (2) and the supporting documentation for the report were maintained for at least 12 months after the date the report was submitted to the governing authority. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

findings: 1. A review of the facility's policies and procedures revealed an undated policy titled "QUALITY ASSURANCE POLICY". The policy stated "Sunflower Living LLC will:...c) The proprietor and the management team will ensure that feedback from service users, staff, observations of working practice, audits, adverse events, incidents, near misses, misconduct, compliments, and complaints is all collated and data/trends identified will be fed back to the management team monthly... i) Provide information and choices which will lead to a healthier lifestyle j) monitor and review the care provided at least annually or more frequently as required to meet the needs of the service user k) Identify, monitor, and manager risk to service users m) Audit communication logs, MAR sheets, falls, medication errors, absences, compliments & complaints...AUDIT At least one quality audit will be conducted on an annual basis..." 2. The Compliance Officer requested to review the facility's report required in subsection (2) and the supporting documentation for the report. However, the report required in subsection (2) and the supporting documentation for the report was not provided for review. 3. In an interview, E1 acknowledged documentation of the report required in subsection (2) and the supporting documentation for the report were not maintained for at least 12 months after the date the report was submitted to the governing authority.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure an individual whose behavioral health issue limits the individual's ability to function independently, received continuous protective oversight. The deficient practice posed a risk to R1 who required continuous protective oversight due to their limited ability to function independently.

findings: 1. A review of the facility's policies and procedures revealed an undated policy titled "QUALITY ASSURANCE POLICY". The policy stated "Sunflower Living LLC will:...i) Provide information and choices which will lead to a healthier lifestyle j) monitor and review the care provided at least annually or more frequently as required to meet the needs of the service user k) Identify, monitor, and manager risk to service users m) Audit communication logs, MAR sheets, falls, medication errors, absences, compliments & complaints." 2. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? Writer suspected that group of teens had been smoking and when teens were confronted [R1] became paranoid admitted guilt and encouraged group of peers to leave facility to avoid getting in trouble. Special Incidents The individual is missing and the vendor has filed a missing persons report with a law enforcement agency. Notifications Police DES caseworker...Review of incident, actions taken, and/or recommended...[R1] was outside with peer's before dinner and asked to come in and get cleaned up to eat. [R1] sat on couch and as writer began to serve pizza it was noted that [R1] was wearing dark shades...following dinner writer noticed [R1's] apprehension to remove glasses. Writer investigated situation. It look as if all 3 teens, [R3] [age], [R4] [age] and [R1] [age] was potentially high with red eyes and delayed responses. Writer questioned if they had been smoking. [R1] and peers denied...Writer asked again to be honest and give up smoke stick if [R1] had one. [R1] pulled [R1's] pockets inside out and a lighter was exposed. Writer asked about the need for a lighter and [R1] responded that 'it's mine, everyone has lighters." [R1] was informed that a drug test would be conducted for the 3 and that they should all go to bed. This made [R1] very paranoid. [R1] asked the writer not to share information with [R1's] team. [R1] asked that writer not call the police...[R1] stated that [R1] may as well as leave because [R1] refuses to go to jail for a smoking violation. [R1] proceeded to [R1's] room as [R1's] peers followed [R1's] lead...[R1] said [R1] would detox before any test, then [R1] admitted to smoking marijuana and asked that it not be exposed. Writer reminded [R1] that [R1] has a standing order to be tested bi weekly and it would be exposed. [R1] left officer and 5 mins later [R1] and [R1's] peers [R3], [R4], and [R2]...lined up at front door to exit home. Writer reminded all of them that they were only making matters worse and the safest most responsible thing to do was to go to bed and get a fresh start tomorrow...Writer explained that the only [sic] for a police to be called out was for [R1] continuing to disrupt home and the encouragement of involving others. [R1] was reminded that [R1] has been caught 3x with vapes in home and all were removed from [R1's] person. [R1] stated [R1] felt bad doing those things and all 4 kids walked out of the home. Police was notified and report was filed...Incident started at about 715 pm during dinner. [R1] left home around 915pm. Staff [E3] rode around neighborhood and also was outside by feet and did not locate [R1] or peers." 3. In an interview, E1 reported E1 searched the premises and R1's belongings, and did not find marijuana. E1 reported R1 took the city bus to and from summer school during the week. E1 reported R1's team and parole officer gave R1 permission to take the city bus unaccompanied. 4. In an interview, E2 reported R1 took the city bus to and from summer school during the week. E2 reported R1's team and parole officer gave R1 permission to take the city bus unaccompanied. 5. In an interview, E1 acknowledged the administrator failed to ensure R1 received 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 use or have access to materials presenting a threat to the resident's health or safety based on the resident's documented diagnosis, treatment needs and personal history. The deficient practice posed a risk as residents had access to marijuana while admitted into a behavioral health residential facility.

findings: 1. A review of the facility's policies and procedures revealed an undated policy titled "QUALITY ASSURANCE POLICY". The policy stated "Sunflower Living LLC will:...i) Provide information and choices which will lead to a healthier lifestyle j) monitor and review the care provided at least annually or more frequently as required to meet the needs of the service user k) Identify, monitor, and manager risk to service users m) Audit communication logs, MAR sheets, falls, medication errors, absences, compliments & complaints." 2. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? Writer suspected that group of teens had been smoking and when teens were confronted [R1] became paranoid admitted guilt and encouraged group of peers to leave facility to avoid getting in trouble. Special Incidents The individual is missing and the vendor has filed a missing persons report with a law enforcement agency. Notifications Police DES caseworker...Review of incident, actions taken, and/or recommended...[R1] was outside with peer's before dinner and asked to come in and get cleaned up to eat. [R1] sat on couch and as writer began to serve pizza it was noted that [R1] was wearing dark shades...following dinner writer noticed [R1's] apprehension to remove glasses. Writer investigated situation. It look as if all 3 teens, [R3] [age], [R4] [age] and [R1] [age] was potentially high with red eyes and delayed responses. Writer questioned if they had been smoking. [R1] and peers denied...Writer asked again to be honest and give up smoke stick if [R1] had one. [R1] pulled [R1's] pockets inside out and a lighter was exposed. Writer asked about the need for a lighter and [R1] responded that 'it's mine, everyone has lighters." [R1] was informed that a drug test would be conducted for the 3 and that they should all go to bed. This made [R1] very paranoid. [R1] asked the writer not to share information with [R1's] team. [R1] asked that writer not call the police...[R1] stated that [R1] may as well as leave because [R1] refuses to go to jail for a smoking violation. [R1] proceeded to [R1's] room as [R1's] peers followed [R1's] lead...[R1] said [R1] would detox before any test, then [R1] admitted to smoking marijuana and asked that it not be exposed. Writer reminded [R1] that [R1] has a standing order to be tested bi weekly and it would be exposed. [R1] left officer and 5 mins later [R1] and [R1's] peers [R3], [R4], and [R2]...lined up at front door to exit home. Writer reminded all of them that they were only making matters worse and the safest most responsible thing to do was to go to bed and get a fresh start tomorrow...Writer explained that the only [sic] for a police to be called out was for [R1] continuing to disrupt home and the encouragement of involving others. [R1] was reminded that [R1] has been caught 3x with vapes in home and all were removed from [R1's] person. [R1] stated [R1] felt bad doing those things and all 4 kids walked out of the home. Police was notified and report was filed...Incident started at about 715 pm during dinner. [R1] left home around 915pm. Staff [E3] rode around neighborhood and also was outside by feet and did not locate [R1] or peers." 3. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? Peers decided to AWOL and [R2] decided [R2] was going with them. [R2] left home at 915 am. At 3 am [R2] was found asleep in driveway. Special Incidents The individual is missing and the vendor has filed a missing persons report with a law enforcement agency. Notifications Police DES caseworker...Review of incident, actions taken, and/or recommended...At 9:15 pm writer found [R2] standing at front door with peers preparing to AWOL. Jesse was told by writer to remove [R2] and to go back to bed and [R2] shook [R2's] head and said "NO" As [R2's] peers began to walk out the door same with bags in the hand, [R2] walked out as well, empty handed and without shoes on. Staff [E3] came in and drove around neighborhood as well search outside home and [R2] nor [R2's] peers were found. Police was called and report was obtained. [R2] along with another peer was found to be outside asleep at about 3am. They were assisted back into home and went to bed." 4. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? [R3] was suspected to have been smoking vape or marijuana and when confronted [R3] became irate and belligerent. [R3] ultimately left home with other peers and did not return. Special Incidents The individual is missing and the vendor has filed a missing persons report with a law enforcement agency...Review of incident, actions taken, and/or recommended...[R3] was questioned about eyes being red and why [R3's] responses were delayed after being outside with peers. [R3] stated that writer was "tweaking" and [R3] accused writer of being high because smoking was being questioned. [R3] denied having any vapes or substances [R3] offered for writer to check [R3's] pockets. [R3] was encouraged to go to be [sic] after dinner and informed of next days schedule. [R3's] peer appeared to be the provider of whatever that had been smoked...[R3's] peer suggested leaving because of [unknown] fear of in trouble with probation and potentially taken back to detention. [R3] was agreeable and immediately packed up a small bag and put shoes on. [R3] appeared to be more of a follower. [R3] left home with 3 other peers at about 915 pm. Staff came in to assisted and walked neighborhood and drove around to nearby stores and gas stations and [unknown] did not see them. A police report was filed..." 5. A review of facility documentation revealed a document titled "Incident report" dated June 8, 2023. The incident report stated "What Happened? [R4] followed group of teens in smoking marijuana and when group of teens planned to leave facility [R4] left facility as well. [R4] returned 7 hours later. Notifications Police case...Review of incident, actions taken, and/or recommended...[R4] has been hanging with 17 year old peer in home. [R4] seemed to be influenced to engage in smoking as writer found [R4] with red eyes and delayed responses. [R4] was questioned about [R4's] eyes being red and [R4] denied having involvement with smoking or drugs and also placed a bet that if [R4] was tested [R4] would pass and joked that when is is [sic] negative writer should give [R4] 10 dollars. However, [R4's] peers were more vocal and admitted to smoking. [R4's] peers were very paranoid and verbalized wanting to leave the facility to avoid getting in trouble. [R4] was encouraged not to worry about the events that took place and to go to bed and rest...After 10 minutes of [R4] talking with [R4's] peers writer found [R4] at the front door behind 2 others with bags packed preparing to leave the facility. [R4] left home with peers at about 915 pm. Staff [E3] came in to assist writer by driving the neighborhood as well as walked the streets and did not see [R4 or 3 others. Police report was filed after they did not return...At 3 am [R4] was found in the backyard asleep on the trampoline. [R4] came into home and went to bed." 6. A review of R1's medical record revealed a behavioral health assessment