summary: Complaint - 1/16/2024

raw_content: An on-site investigation of complaint AZ00194939, AZ00195093, AZ00196373, and AZ00203016 was conducted on January 16, 2024 and the following deficiencies were cited :

rule: C. An administrator shall ensure that a resident's medical record contains: 9. Orders;

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident's medical record contained orders, for one of five residents sampled. The deficient practice posed a risk as medication administration could not be verified against a medication order.

findings: 1. A review of facility documentation revealed an incident reported dated March 26, 2023. The report stated "Staff [E3] gave individual [R1] two tabs of Prazosin 1 mg instead of one tab Prazosin 1 mg as prescribed." 2. A review of R1's medication administration record (MAR) for the month of March 2023 revealed R1 received medication administration for Prazosin 1 mg on the following dates: March 22-31, 2023. 3. A review of R1's medical record revealed a medication order for Prazosin 1 mg was not available for review. 4. In a joint interview, E4, E5, E6, and E9 acknowledged R1's medical record did not contain a medication order.

rule: B. If a behavioral health residential facility provides medication administration, an administrator shall ensure that: 3. A medication administered to a resident: a. Is administered in compliance with an order, and

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

findings: 1. A review of facility documentation revealed an incident report, dated April 13, 2023. The incident report stated "During this reconciliation, staff [E7] discovered that indiv [sic] [R2] Clonidine 0.1 mg was off count. Staff on [E7] checked with staff [E8] DCP, BHT, who had administered the P.M. medication earlier. Staff determined that indiv [sic] [R2] was given Clonidine 0.1 mg half tab and [R2] was prescribed to get Clonidine 0.1 mg whole tab. Staff [E8] gave the half tab based on the medication administration record prepared by nursing which stated "PM- Take- Take 1/2 tablet by mouth'. The instructions on the MAR were incorrect and inconsistent with the medication packaging which read to take a whole tab." 2. A review of R2's medical record revealed a medication order dated April 13, 2023. The order stated "Clonidine 0.1 mg...1 tab PO HS" 3. A review of R2's medication administration record (MAR) for the month of April 2023 revealed two separate MARs for April 2023. The first MAR revealed R2 received medication administration for Clonidine 0.1 mg on the following dates and times: April 13, 2023 during the "PM" timeslot, the MAR stated "Clonidine 0.1 mg take 1/2 tablet by mouth twice daily" the count was indicated as half of a dose of Clonidine 0.1 mg was administered by staff, in correspondence with the aforementioned incident report. Additionally, R2 was administered "Clonidine 0.1 mg 1 tablet" during the "PM" timeslot on April 14-20, 2023 on the second corrected MAR. 4. A review of facility documentation revealed an incident report, dated September 11, 2023. The incident report stated "Individual [R3]...Medications were received by RN [E10], medications were locked in drawer for safety purposes. Medications were left in drawer unaccounted for and the individual did not receive medications for 9/9/2023-9/10/2023 [medications include Concerta ER 27 mg, Sertraline 75 mg, and Guanfacine ER 1 mg, Hydroxyzine 50 mg]. On 9/11/2023 Individual did not receive Concerta ER 27 mg." 5. A review of R3's medical record revealed a medication order dated August 31, 2023. The order stated "...Continue Hydroxyzine 50 mg qhs for sleep...continue Guanfacine 1 mg qd for inattention/concentration...continue Methylphenidate to 27 mg qd for inattention/concentration...continue Sertraline to 75 mg qd for depression/anxiety." 6. A review of R3's medication administration record (MAR) for the month of September 2023 revealed R3 received medication administration for the following medications on the following dates and times: -"Concerta ER 27 mg take 1 tablet by mouth every morning" on September 12-29, 2023; -"Guanfacine ER 1 mg take 1 tablet by mouth every morning" on September 11-26. 2023; -"Sertraline 50 mg take 1.5 mg tablets by mouth every morning" on September 11-30, 2023; and -"Hydroxyzine 50 mg take 1 capsule by mouth at 8 PM" on September 11-30, 2023. 7. In a joint interview, E4, E5, E6, and E9 acknowledged R2's and R3's medications were not administered in compliance with R2's and R3's medication orders.


state: AZ

facility_name: DEVEREUX ARIZONA - BROADWAY CAMPUS

summary: Complaint - 4/24/2023

raw_content: An on-site investigation of complaint AZ00194328 was conducted on April 24, 2023 and no deficiencies were cited.

inspection_type: Complaint


summary: Compliance (Annual) - 4/14/2023

raw_content: Based on Arizona Revised Statutes, \'a736-424(B) and Arizona Administrative Code, R9-10-109(E), the Department may not conduct an onsite compliance inspection during the time of the accreditation report. The licensee submitted to the Department the current accreditation report from The Joint Commission, valid from November 5, 2023 through November 5, 2025. If the health care institution's accreditation report is not valid for the entire licensing fee period of April 29, 2023 through March 31, 2024, the Department may conduct a compliance inspection of the health care institution during the time period the department does not have a valid accreditation report for the health care institution.

inspection_type: Compliance (Annual)


summary: Complaint - 4/10/2023

raw_content: An on-site investigation of complaint AZ00190979 was conducted on April 10, 2023 and the following deficiency was cited :

rule: F. An administrator shall ensure that a personnel member immediately reports a medication error or a resident's adverse reaction to a medication to the medical practitioner who ordered or prescribed the medication and, if applicable, the behavioral health residential facility's clinical director.

evidence: Based on record review and interview, the administrator failed to ensure a personnel member immediately reported a medication error to the medical practitioner who ordered or prescribed the medication, for one of two resident records reviewed.

findings: A.A.C. R9-10-101(135) "Medication error" means: a. The failure to administer an ordered medication; b. The administration of a medication not ordered; or c. The administration of a medication: i. In an incorrect dosage, ii. More than 60 minutes before or after the ordered time of administration unless ordered to do so, or iii. By an incorrect route of administration. 1. A review of R1's medical record revealed the following medication orders: - "Escitalopram 20mg tablet: take 1 tablet every morning ..."; - "Prazosin 1 mg PO qhs"; and - "Aripiprazole 20 mg Oral Nightly at Bedtime". 2. A review of R1's Medication Administration Record (MAR) dated "January/2023", revealed the following: - Escitalopram 20mg, 1 tablet, was to be provided at "8AM"; - Prazosin 1 mg, 1 capsule, was to be administered at "8PM"; and - Aripiprazole 20 mg, 1 tablet, was to be administered at "8PM". 3. The MAR indicated the following medications were provided more than 60 minutes after the ordered time of administration: - Escitalopram was administered at 9:28AM on January 9, 2023; - Prazosin was administered at 6:53PM on January 9, 2023, and; - Aripiprazole was administered at 6:52PM on January 9, 2023. 4. In an interview E1 acknowledged there was no documentation the medication errors were immediately reported to the medical practitioner who ordered or prescribed the medications.


facility_name: GENERATIONS GROUP HOME

summary: Complaint;Compliance (Annual) - 1/15/2026

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00156135 conducted on January 15, 2026:

inspection_type: Complaint;Compliance (Annual)

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 and interview, the administrator failed to ensure a personnel record was maintained to include documentation of the individual's compliance with requirements in A.R.S. § 36-411, for two of four personnel records sampled. The deficient practice posed a risk if personnel were a danger to a vulnerable population and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: A.R.S. § 36-411.C.5: 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant (APS) to section 46-459. 1. A review of E2 and E3's, personnel records revealed no documentation of annual reverification that E2 and E3 were not on the adult protective services registry pursuant (APS) to section 46-459. 2. A review of the APS registry revealed E2 and E3 were not on the APS registry in accordance with A.R.S. § 36-411.C.5. 3. In an exit interview, the findings were discussed and E5 reported the documentation was in a pile of paperwork, and was not able to locate it during the on-site inspection. No additional statement or documentation was provided. This is a repeated violation from the complaint inspection conducted on September 13, 2023, the complaint and compliance inspection conducted on February 3, 2025, and the complaint inspection conducted on June 25, 2025.

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), within 24 hours, a behavioral health professional (BHP), certified or licensed to provide the behavioral health services needed by the resident was reviewed and signed the behavioral health assessment to ensure the behavioral health assessment identified the behavioral health services needed by the resident, for one of two medical records sampled. The deficient practice posed a risk if an analysis of the resident's needs for behavioral health services and to determine services to be provided was not reviewed and approved by a qualified BHP and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of R1's medical record revealed a behavioral health assessment titled, "Resident Initial Intake and Admission Psychosocial Assessment" conducted by a BHT in 2025. However, the assessment was not reviewed and signed by a BHP. 2. In an interview, E5 acknowledged the missing signature from the behavioral health assessment for R1. 3. In an exit interview, the findings were reviewed with E5 and no additional comments, statements or documentation was provided regarding the findings. This is a repeated violation from the complaint investigation conducted on June 25, 2025.

rule: R9-10-707.A.11.a.i-ix. Admission; Assessment 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 to ensure a behavioral health assessment documented the resident's presenting issue, co-occurring disorder, criminal justice record, family history, and symptoms reported by the resident for one of two sampled residents. The deficient practice posed a risk if staff were not able to determine the primary condition for which the resident was admitted and treatment needs were within the facilities scope of services, and were based on the resident's current state.

findings: 1. A review of R1's medical record revealed a document titled, "Resident Initial Intake and Admission Psychosocial Assessment" dated in 2025. 2. A review of R1's assessment (dated in 2025) revealed the presenting issue and co-occurring disorders sections noted with, "See attachments". A further review of the assessment revealed the following sections left blank or not included in the behavioral health assessment: criminal justice record, family history, and symptoms reported by the resident. 3. The Compliance Officer requested to view the relevant attachments; however, E5 reported to be unable to find the attachments for review. 4. In an exit interview, the findings were reviewed with E5, and no additional comments, statements, or documents were provided regarding the findings.

rule: R9-10-707.A.13.a. Admission; Assessment 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

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 resident records sampled. The deficient practice posed a TB exposure risk to residents and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of R1's medical record revealed documentation of tuberculin skin test results from "Chiricahua Community Health Centers, Inc" completed thirty calendar days after R1's admission. The record did not include any documentation of evidence of freedom from infectious tuberculosis before or within seven calendar days after the R1's admission. 2. In an exit interview, the findings were reviewed with E5 and no additional comments, statements, or documentation were provided regarding the findings. This is a repeated violation from the complaint investigation conducted on June 25, 2025.

rule: R9-10-712.C.11. Medical Records 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 documentation of a nursing assessment, for one of two residents sampled. The deficient practice posed a risk if the residents needs were outside the scope and the facility was unable to verify if the facility was able to meet the residents needs.

findings: 1. A review of R1’s medical records revealed no documentation of a nursing assessment, or a medical history and physical exam. 2. In an interview, E5 reported R1 had a nursing assessment completed, but the documentation was in a pile of paperwork and E5 could not locate the documentation. 3. In an exit interview, the findings were reviewed with E5, and no further comments, statements or documentation were provided regarding the findings.

rule: R9-10-712.C.12. Medical Records C. An administrator shall ensure that a resident's medical record contains: 12. Treatment plans;

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained a treatment plan, for two of two medical records sampled. The deficient practice posed a risk as there was no treatment plan to direct services to be provided to a resident.

findings: 1. A review of R1's medical record revealed a treatment plan dated September 2025. The treatment plan revealed a review date of October 2025. However, R1's medical record revealed no documentation of an updated treatment plan. 2. A review of R2's medical record revealed a treatment plan dated October 2025. The treatment plan revealed a review date of November 2025. However, R2's medical record revealed no documentation of an updated treatment plan. 3. In an interview, E5 reported R1 and R2 had current treatment plans; however, E5 was unable to locate R1's and R2's updated treatment plans due to it being in a pile of paperwork. 3. In an exit interview, the findings were reviewed with E5, and no additional comments, statements, or documents were provided regarding the findings.

rule: R9-10-712.C.18. Medical Records C. An administrator shall ensure that a resident's medical record contains: 18. Except as allowed in R9-10-707(E)(1)(d), documentation of freedom from infectious tuberculosis required in R9-10-707(A)(13);

evidence: Based on record review and interview, the administrator failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB) required in R9-10-707.A.13, for one of two medical records sampled. The deficient practice posed a potential TB exposure risk to individuals within the facility and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of R2's medical records revealed no documentation of freedom from infectious TB as required in R9-10-707.A.13 to include evidence of a negative Mantoux skin test or other TB screening test. 2. In an interview, E5 reported R2 had a negative TB test completed within the first week of being admitted, and was completed at "Chiricahua Clinic", however, E5 was unable to locate the documentation due to it being in a pile of paperwork. 3. In an exit interview, the findings were discussed with E5, and no additional comments, statements or documents were provided regarding the findings. This is a repeated violation from the compliant and compliance inspection conducted on February 3, 2025.

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

evidence: Based on 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 two medical records sampled. The deficient practice posed a risk to R1's health and safety as medications were provided to R1 without verifying the medication matched current medication orders, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of R1's medical record revealed a medication administration record (MAR) dated January 2026. The MAR revealed R1 received assistance in the self-administration for the following medications: "Benztropine Mesylate 1MG", "Haloperidol 5MG", "Hydroxyzine 50MG", "Divalproex Sodium 750MG", and "Prazosin HCL 6mg". However, R1's medical record did not contain medication orders for the aforementioned medications. 2. The Compliance Officer requested medication orders for R1. However, E5 reported to not have medication orders. 3. The Compliance Officer observed R1's medication containers to be the same as the medications listed on R1's MAR. 4. In an exit interview, the findings were reviewed with E5 and no additional comments or statements were provided regarding the findings. This is a repeated violation from the compliant and compliance inspection conducted on February 3, 2025.

rule: R9-10-720.C.3. Emergency and Safety Standards C. An administrator shall: 3. Maintain documentation of a current fire inspection.

evidence: Based on observation and interview, the administrator failed to maintain documentation of a current fire inspection. The deficient practice posed a potential risk to the health and safety of a resident in the event of a fire if hazards have not been identified and corrected, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. The Compliance Officer observed a fire inspection posted near the front door, titled "Sierra Vista Fire & Medical Services" which indicated it had expired on July 14, 2023, and was to be inspected annually. 2. In an interview, E5 reported difficulties scheduling a current fire inspection but had an updated fire inspection. However, E5 was unable to locate the fire inspection for review. 3. In an exit interview, the findings were reviewed with E5 and no additional comments, statements or documents were provided. This is a repeated violation from the compliant and compliance inspection conducted on February 3, 2025.

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 premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a threat to the health and safety of residents and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. The Compliance Officer observed on the exterior premises where residents had access to: two broken basketball hoops, storage of materials and tools that were leaning and blocking pathways near the exit of the building, posts and broken metal in and around the exterior premises, fallen and broken gutters, and tools not stored in a designated area. 2. In an interview, E5 reported one basketball hoop was going to be fixed by putting plexiglass over the damaged area of the backboard, and the other basketball hoop was going to be hauled away; the materials were going to be thrown away and removed or stored in a designated area, and the damaged gutters were to be repaired soon. 3. In an exit interview, the findings were reviewed with E5 and no additional comments or statements were provided regarding the findings. This is a repeated violation from the compliance inspection and complaint investigation conducted on February 3, 2025, and June 25, 2025.


summary: Complaint - 10/3/2025

raw_content: The following deficiencies were found during the on-site investigation of complaints 00146460, 00146648, and 00147095 were conducted on October 3, 2025.

rule: R9-10-113.A.2.a-f. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

evidence: Based on record review, documentation review, and interview, the administrator failed to establish, document, and implement tuberculosis (TB) infection control activities which included annual training and education related to recognizing the signs and symptoms of TB provided to individuals employed by the facility, for four of eight personnel records sampled. The deficient practice posed a risk as there were no policies and procedures to reinforce and clarify the behavioral health residential facility’s standards.

findings: R9-10-113.A.2.c. "A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution;" 1. A review of E2's personnel record (hired June 2021) revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 2. A review of E3's personnel record (hired April 2024) revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 3. A review of E4's personnel record (hired November 2021) revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 4. A review of E8's personnel record (hired April 2024) revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 5. A review of facility documentation revealed the administrator failed to develop a training program for all staff regarding training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution. 6. In an exit interview, the findings were reviewed with E1, and no additional documentation was provided.

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

evidence: Based on record review, documentation review, and interview, the administrator failed to maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence that included the name of the resident, name of the individual to whom the report was submitted, and date of the report. The deficient practice posed a risk if the facility did not maintain the required documentation to evaluate and take action related to the unauthorized absences of residents and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: 1. A review of R1’s and R4’s medical records revealed a police report from September 21, 2025. The police report stated, “Date: 09/21/2025…Time: 20:00…OFFENSE DESCRIPTION: THEFT-SHOPLIFTING OF GOODS ON DISPLAY-VALUE LT 100…OFFENSE DESCRIPTION: RUNAWAY… DETAILS OF OFFENSE(S): ON 09/21/2025 AT APPROXIMATELY 1900 HOURS, [R4] AND [R1] WERE RECORDED AT THE SV SMOKE SHOP SHOPLIFTING VAPES. THE TWO WERE ALSO ABSENT FROM THE GENERATIONS GROUP HOME WITHOUT PERMISSION.” 2. A review of facility documentation revealed an Absent Without Leave (AWOL) log. The AWOL log revealed R1 and R3 left the facility on September 21, 2025, at 3:30 PM. This incident was documented in the AWOL log and supported by an incident report in R1’s and R3’s medical records. However, the unauthorized absence for R1 and R4 leaving the facility on September 21, 2025 around 7:00 PM, was not documented in the AWOL log. 3. A review of the facility's policies and procedures had a policy titled, "R9-10-703.I.5.6 Establish and document the criteria for determining when a resident's absence is unauthorized." The policy stated, "...AWOL incidents will be documented in the AWOL log and GGH IR." 4. In an interview, E1 reported on September 21, 2025 around 7:00 PM, R1 and R4 left the facility, went to the corner store, and to the mall. 5. In an interview, E1 reported on September 26, 2025, R1, R2, R3, and R4 left the facility from 6:53 PM to 7:42PM. E1 reported R1, R2, R3, and R4 went to the mall. E1 also reported the facility forgot to document the incident in the facility’s Absent Without Leave (AWOL) log. 6. In an exit interview, the findings were reviewed with E1and no further statements or documentation were provided. This is a repeat violation from the on-site compliance inspection completed on June 1, 2022.


summary: Complaint - 6/25/2025

raw_content: An on-site investigation of complaint 00134592 was conducted on June 25, 2025, and the following deficiencies were cited:

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

evidence: Based on documentation review, record review and interview, the administrator failed to administer a training program for all staff, which included continued competency training in fall prevention and fall recovery, for two of six personnel members sampled. The repeated deficiency posed a risk to the health and safety of residents if personnel were not receiving scheduled training in fall prevention and fall recovery training according to policies and procedures.

findings: 1. A review of facility documentation revealed a policy and procedure, dated June 2024, which stated, "The training program shall include initial training and continued competency training in fall prevention and fall recovery....GGH's initial training on fall prevention and fall recovery will include continued competency training using the azstopfalls.org resource documents during scheduled quarterly training sessions. Training(s) on fall prevention and fall recovery will be documented and placed into the employees' personnel file..." 2. A review of E4's (hired 2021) personnel record revealed initial training in fall prevention and fall recovery, dated in 2023. However, there was no documentation of E4's continued competency training in fall prevention and fall recovery. 3. A review of E6's (hired 2021) personnel record revealed initial training in fall prevention and fall recovery, dated in 2023. However, there was no documentation of E6's continued competency training in fall prevention and fall recovery. 4. In an exit interview, the findings were reviewed with E1, and no additional statements or documentation were provided. This is an uncorrected deficiency from the compliance and complaint investigation completed February 3, 2025.

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

evidence: Based on documentation review 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 health and safety risk for residents if personnel were unable to ensure resident safety.

findings: 1. A review of facility documentation revealed an incident report dated June 2025, created by E6, the administrator and behavioral health technician. The report stated, "[R3] had come into staff office stating "I don't want to be here anymore." When asked why, [R3] stated "cause"... [R3] and counselor had a brief conversation about helping [R3] to state why. [R3] then stated "I'm going downstairs, counselor informed [R3], [R3] could not be downstairs by [themself]... [R3] stated, "You are triggering me." [R3] began walking around downstairs.... [R3] took the time to walk out the door [R3] was called back. [R3] said "no, I don't want to be here anymore." I, [E6] the counselor stood in front of [R3] and turned [R3] around. [R3] walked by the van in the parking lot. When [R3] could not pass me, [R3] land on the ground and started to band [R3's] forehead on the cement. [R3's] jacket was removed and placed under [R3's] head so [R3] could not hurt [themself]. [R3] then began to kick and move [R3's] arm to [R3's] self. Staff held [R3] still to keep [R3] safe. When law enforcement arrived, the entire time [R3] was refusing to get up and go inside." [R3] was transported to [medical center] with injuries: bloody nose, red marks on legs, and wrist." 2. In an interview, R1 reported being instructed by E6 to "hold down" R3 because E6 had back issues. 3. In an interview, R2 reported being instructed by E6 to help with "holding down" R3 while on the ground. 4. In an interview, E6 disclosed having back issues and reported having instructed R1 to assist with controlling R3's behavior. E6 also reported that R2 assisted with "holding down" R3 while R3 was on the ground. 5. In an exit interview, the findings were reviewed with E1, who reported not being aware R1 and R2 had assisted in "holding down" R3 while R3's behavior was out of control. E6 failed to ensure the safety of R3 as per R9-10-706.B.3.c.

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 documentation review, record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member, employee, volunteer, or student that included documentation of the individual's compliance with the requirements in A.R.S. § 8-804, for five of six personnel records sampled. The deficient practice posed a safety risk for residents if personnel did not clear a Department of Child Safety (DCS) registry check before working with vulnerable residents under 18 years of age.

findings: A.R.S. 8-804. states, "The department shall conduct central registry background checks and shall use the information contained in the central registry only for the following purposes: -As a factor to determine qualifications for any of the following: (g) An adult who works in a group home, residential treatment center, shelter or other congregate care setting." 1. A review of Department documentation revealed BH6723 was licensed as a behavioral health residential facility to provide services to residents under the age of 18 in July 2021. 2. A review of E3's, E4's, E5's, E6's, and E7's personnel records revealed no evidence of a DCS registry check as required, according to A.R.S. §8-804. 3. In an exit interview, the findings were reviewed with E1, who did not provide additional comments or documentation.

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a personnel record was maintained for each personnel member, employee, volunteer, or student that included documentation of an individual's compliance with requirements in A.R.S. § 36-425.03, as applicable for one of six personnel records sampled. The repeated deficient practice posed a safety risk for residents if personnel had not completed a notarized criminal history affidavit before working with vulnerable residents under 18 years of age.

findings: A.R.S. § 36-425.03(E) 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. 1. A review of Department documentation revealed BH6723 was licensed as a behavioral health residential facility to provide services to residents under the age of 18 in July 2021. 2. A review of facility documentation revealed a policy and procedure, dated June 2024, titled "R9-10-703. Administration." The policy stated "A notarized crime free affidavit per ARS 36-425.3.A [sic] will also be required of all GGH staff personnel before employment that will be kept in the staff member's personnel file..." 3. A review of E2's personnel record revealed no evidence of a notarized criminal history affidavit as required and according to 36-425.03. 4. In an exit interview, the findings were reviewed with E1, who did not provide additional comments or documentation. This is an uncorrected deficiency from the compliance inspection and complaint investigation conducted on February 3, 2025, and repeated deficiency from the complaint investigation conducted on September 13, 2023.

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 three resident medical records sampled. The deficient practice posed an exposure risk to residents.

findings: 1. A review of R1's medical record (admitted in 2024) revealed no documentation of R1's freedom from infectious TB dated before or within seven calendar days after the resident's admission. 2. In an exit interview, the findings were reviewed with E1, who reported R1's medical record did not include evidence of freedom from infectious TB because R1's prior facility did not send one.

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, certified or licensed to provide the behavioral health services needed by the resident, reviewed and signed the behavioral health assessment to ensure the behavioral health assessment identified the behavioral health services needed by the resident for one of three resident medical records sampled.

findings: 1. A review of R3's medical record (admitted in 2025) revealed R3's behavioral health assessment was completed by E6, a BHT. However, the behavioral health assessment was not reviewed and signed by a behavioral health professional within 24 hours. 2. In an exit interview, the findings were reviewed with E1, who did not offer any comments or additional documentation.

rule: R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was not subjected to restraint. The deficient practice is a violation of resident rights.

findings: 1. A review of facility policies and procedures dated in 2023 revealed a section titled "Sudden Resident Outbursts", which stated "shall be addressed using de-escalation techniques as the primary means of conflict resolution. The use of restrictive techniques will not be utilized by anyone not certified and verified to do so. Even if a BHP/BHT is certified, verified, and documented in the use of emergency SAFETY RESPONSE, THIS TECHNIQUE WILL NOT BE UTILIZED by GGH Inc. staff." 2. A review of facility documentation revealed an incident report dated June 2025, created by E6, the administrator and behavioral health technician. The report stated, "[R3] had come into staff office stating "I don't want to be here anymore." When asked why, [R3] stated "cause"... [R3] and counselor had a brief conversation about helping [R3] to state why. [R3] then stated "I'm going downstairs, counselor informed [R3], [R3] could not be downstairs by [themself]... [R3] stated, "You are triggering me." [R3] began walking around downstairs.... [R3] took the time to walk out the door [R3] was called back. [R3] said "no, I don't want to be here anymore." I, [E6] the counselor stood in front of [R3] and turned [R3] around. [R3] walked by the van in the parking lot. When [R3] could not pass me, [R3] land on the ground and started to band [R3's] forehead on the cement. [R3's] jacket was removed and placed under [R3's] head so [R3] could not hurt [themself]. [R3] then began to kick and move [R3's] arm to [R3's] self. Staff held [R3] still to keep [R3] safe. When law enforcement arrived, the entire time [R3] was refusing to get up and go inside." [R3] was transported to [medical center] with injuries: bloody nose, red marks on legs, and wrist." 3. In an interview, R1 reported being instructed to "hold down" R3 by E6 because E6 had back issues. 4. In an interview, R2 reported having been instructed by E6 to help with "holding down" R3 while on the ground. 5. In an interview, E6 disclosed having back issues and reported having instructed R1 to assist with controlling R3's behavior. E3 also reported R2 assisted with "holding down" R3 while R3 was on the ground. 6. In an exit interview, the findings were reviewed with E1, who reported not being aware R1 and R2 had assisted in "holding down" R3 while R3's behavior was out of control.

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

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice is a violation of resident rights.

findings: 1. A review of facility policies and procedures dated in 2023 revealed a section titled "Sudden Resident Outbursts", which stated "shall be addressed using de-escalation techniques as the primary means of conflict resolution. The use of restrictive techniques will not be utilized by anyone not certified and verified to do so. Even if a BHP/BHT is certified, verified, and documented in the use of emergency SAFETY RESPONSE, THIS TECHNIQUE WILL NOT BE UTILIZED by GGH Inc. staff." 2. A review of facility documentation revealed an incident report dated June 2025, created by E6, the administrator and behavioral health technician. The report stated, "[R3] had come into staff office stating "I don't want to be here anymore." When asked why, [R3] stated "cause"... [R3] and counselor had a brief conversation about helping [R3] to state why. [R3] then stated "I'm going downstairs, counselor informed [R3], [R3] could not be downstairs by [themself]... [R3] stated, "You are triggering me." [R3] began walking around downstairs.... [R3] took the time to walk out the door [R3] was called back. [R3] said "no, I don't want to be here anymore." I, [E6] the counselor stood in front of [R3] and turned [R3] around. [R3] walked by the van in the parking lot. When [R3] could not pass me, [R3] land on the ground and started to band [R3's] forehead on the cement. [R3's] jacket was removed and placed under [R3's] head so [R3] could not hurt [themself]. [R3] then began to kick and move [R3's] arm to [R3's] self. Staff held [R3] still to keep [R3] safe. When law enforcement arrived, the entire time [R3] was refusing to get up and go inside." [R3] was transported to [medical center] with injuries: bloody nose, red marks on legs, and wrist." 3. In an interview, R1 reported being instructed to "hold down" R3 because E6 had back issues. 4. In an interview, R2 reported being instructed by E6 to help with "holding down" R3 while on the ground. 5. In an interview, E6 disclosed having back issues and reported having instructed R1 to assist with controlling R3's behavior. E6 also reported R2 assisted with "holding down" R3 while R3 was on the ground. 6. In an exit interview, the findings were reviewed with E1, who reported not being aware R1 and R2 had assisted in "holding down" R3 while R3's behavior was out of control.

rule: R9-10-719.A.1.a. Food Services A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 1. For a behavioral health residential facility that has a licensed capacity of more than 10 residents: a. The behavioral health residential facility obtains a license or permit as a food establishment under 9 A.A.C. 8, Article 1; and

evidence: Based on observation, documentation review, and interview, the administrator failed to ensure a behavioral health residential facility, with a licensed capacity of more than 10 residents, obtained a license or permit as a food establishment under 9 A.A.C. 8, Article 1.

findings: 1. The Compliance Officer observed a conspicuously posted food establishment license with a location address of BH6723. However, the food establishment license revealed an expiration date of "10/31/2024." 2. In an interview, the findings were reviewed with E1, who reported an error in processing the food establishment license issued by the Cochis County Health Department, and added E1 was trying to get the issue corrected. This is an uncorrected deficiency from the compliance and complaint investigation completed February 3, 2025.

evidence: Based on observation, record review, and interview, the administrator failed to ensure the premises and equipment were free from a condition or situation which may cause a resident or other individual to suffer physical injury. The repeated deficient practice posed a threat to the health and safety of residents, as the repeated deficiency has not been corrected since the last inspection.

findings: 1. The Compliance Officer observed male and female bathrooms in the facility, downstairs. The Compliance Officer observed two grab bars in the standing shower in both the male and female bathrooms, for a total of four grab bars. The grab bars were not designed to minimize the opportunity for a resident to cause self-injury. 2. The Compliance Officer observed a glass mirror, which was not shatterproof, in the female bathroom. When E1 was informed of this deficiency, E1 pointed to a piece of plexiglass, which was leaning up against the side of the bathroom wall, and stated, "The plexiglass will be installed over the glass soon." 4. A review of R1's (admitted in 2024) medical record revealed no documented assessment or treatment plan for R1. E1 reported, "We are still working on it." It is unknown if R1 had self-harming, suicidal behaviors, which posed a health and safety risk for the resident. 5. A review of R3's medical record (admitted in 2025) revealed a document of R3's visit to a medical center, which stated under "Diagnosis" "nausea and vomiting, suicidal ideation." 6. In an exit interview, the findings were reviewed with E1, who reported having been cited for the same deficiencies last inspection. This is an uncorrected deficiency from the compliance and complaint investigation completed February 3, 2025.

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

evidence: Based on observation and interview, the administrator failed to ensure poisonous or toxic materials stored by the behavioral health residential facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents. The repeated deficient practice posed a health and safety risk to residents.

findings: 1. The Compliance Officer observed an unsecured laundry room in the facility, which contained a plastic container of "Oxy Clean" laundry detergent on top of the washing machine. 2. In an exit interview, the findings were reviewed with E1, who reported being aware of the unsecured laundry detergent and stated, "the residents do their laundry." This is an uncorrected deficiency from the compliance and complaint investigation completed February 3, 2025, and repeated deficiency for the compliance and complaint investigation completed May 31, 2023.


summary: Complaint - 2/12/2024

raw_content: An on-site investigation of complaint AZ00201877 was conducted on February 12, 2024 and no deficiencies were cited.


summary: Complaint - 9/13/2023

raw_content: An on-site investigation of complaints AZ00200523 and AZ00200475 was conducted on September 13, 2023 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 the facility's premises with the qualifications, experience, skills and knowledge necessary to meet the needs of a resident and ensure the health and safety of a resident.

findings: 1. A review of the facility's work schedule revealed E5 worked alone on the 8 am to 8 pm shift on Saturday, September 2, 2022, Sunday, September 3, 2023, Saturday, September 9, 2023, and Sunday, September 10, 2023, and worked alone on the 4 pm to 12 am shift on Monday September 1, 2023, Monday, September 4, 2023, Tuesday September 5, 2023, and Friday, September 8, 2023. 2. A review of E5's personnel record revealed E5 was hired as a behavioral health paraprofessional (BHPP) in May of 2023. However, E5's personnel record did not include documentation of cardiopulmonary resuscitation (CPR) training certification or first aid training certification. 3. In an interview, E1, E2, and E3 acknowledged E5 did not have CPR or First Aid training and did not have the skills necessary to work alone at the facility.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained to include documentation of compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for one of two personnel members sampled.

findings: 1. A.R.S. \'a7 36-411(C)(1) states: "Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency." 2. A review of E5's personnel record revealed E5 was hired as a behavioral health paraprofessional (BHPP). E5's personnel record also contained an employment application with a section to list prior employer contact information and to include an employment history, and documented previous employers. However, documentation of good faith efforts to contact previous employers included only one documented contact with a previous employer. 3. In an interview, E1, E2, and E3 acknowledged the personnel record provided for E5 did not include documentation of compliance with A.R.S. \'a7 36-411(C).

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 two behavioral health paraprofessionals (BHPP) sampled. The deficient practice posed a risk if E5 was unable to respond or assist a resident in the event of an emergency.

findings: 1. A review of the facility's work schedule revealed E5 worked alone on the 8 am to 8 pm shift on Saturday, September 2, 2022, Sunday, September 3, 2023, Saturday, September 9, 2023, and Sunday, September 10, 2023, and worked alone on the 4 pm to 12 am shift on Monday September 1, 2023, Monday, September 4, 2023, Tuesday September 5, 2023, and Friday, September 8, 2023. 2. A review of E5's personnel record revealed E5 was hired as a behavioral health paraprofessional (BHPP) in May of 2023. However, E5's personnel record did not include documentation of cardiopulmonary resuscitation (CPR) training certification or first aid training certification. 3. In an interview, E1, E2, and E3 acknowledged E5' s personnel record did not include documentation of CPR training and first aid training certification.

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 for each resident was reviewed and updated on an on-going basis according to the review date specified in the treatment plan, for one of two residents sampled.

findings: 1. A review of R2's medical record revealed a treatment plan dated June 30, 2023. The treatment plan include a review date of July 30, 2023. However, a treatment plan review dated on or before July 30, 2023 was not provided for review. 2. In an interview, E1, E2, and E3 acknowledged a treatment update for R2, dated on or before July 30, 2023, had not been provided for review.


summary: Complaint;Compliance (Annual) - 5/31/2023

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint # AZ00194649 conducted on May 31, 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 an individual was not designated to act on behalf of the governing authority if the administrator was not present, a designated individual was not present on the premises when E4 was not present on the premises, 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. Upon arriving at the facility, the Compliance Officer observed E3 and E8 working at the facility. The Compliance Officer observed the administrator was not present at any time during the on-site inspection. 2. The Compliance Officer requested to review documentation of the designation of each accountable individual who was present when the administrator was not present at the facility, however, no documentation was provided for review. 3. In an interview, E1 acknowledged the required designation documentation had not been provided for review.

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 to review documentation of the designation of accountable individuals by the administrator per R9-10-703(B)(3). However, this documentation was not provided for reviw. 2. In an interview, E1 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request.

rule: K. An administrator shall ensure that: 3. There is a daily staffing schedule that: b. Includes documentation of the employees who work each calendar day and the hours worked by each employee; and

evidence: Based on documentation review, and interview, the administrator failed to ensure a daily staffing schedule included documentation of the employees who work each calendar day and the hours worked by each employee.

findings: 1 A review of the facility work schedule for May 2023 revealed the schedule did not include any work hours for E1, E4, E5, E6, or E7. 2. In an interview, E1 reported the salaried staff, the clinical director, and the facility nurse do not have fixed schedules but all work at the facility regularly. E1 acknowledged the daily staffing schedule provided for review did not include documentation of the employees who work each calendar day and the hours worked by each employee. 3. This is a repeat deficiency from the on-site complaint inspection conducted on April 18, 2023.

rule: A. An administrator shall ensure that: 11. A behavioral health assessment: b. Includes: iii. The signature and date signed of the personnel member conducting the behavioral health assessment; and

evidence: Based on record review and interview, the administrator failed to ensure a behavioral health assessment included the signature and date signed by the personnel member conducting the behavioral health assessment, for one of two residents sampled.

findings: 1. A review of R2's medical record revealed a behavioral health assessment titled, "Resident Initial Intake and Admission Psychosocial Assessment," completed the day of R2's admission. However, the behavioral health assessment did not include the signature and date signed by the personnel member conducting the behavioral health assessment. 2. In an interview, E1 acknowledged R2's behavioral health assessment did not include the signature and date signed by the personnel member who conducted the behavioral health assessment.

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 documention review, 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 R2's medical record revealed a treatment plan updated April 25, 2023. The treatment plan stated R2 would receive, "Individual, family, and group therapy a minimum of 1x weekly in each modality up to 1 hour per session." 2. A review of counseling notes for the month of April 2023 revealed R2 had received the following counseling: - April 5, 2023, Group Therapy, 1 hour; - April 6, 2023, Group Therapy, 1 hour; and - April 20, 2023, Group Therapy, 1 hour. 3. A review of counseling notes for the month of May 2023 revealed R2 had received the following counseling: - May 3, 2023, Group Therapy, 1 hour; and - May 4, 2023, Group Therapy, 1 hour. 4. In an interview, E1 stated the counseling notes provided for R2 did not document counseling was provided according to the frequency and number of hours identified in the resident's treatment plan.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

evidence: Based on documentation review and interview, the administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months.

findings: 1. A review of facility documentation revealed a work schedule indicating the facility worked on three shifts, from 8 AM to 4 PM, from 4PM to 12 AM, and from 12 AM to 8 AM. 2. In an interview, E1 reported the shift pattern has altered with staffing levels and the facility was on two shifts before starting the current three shift pattern. 3. A review of facility documentation from the previous twelve months revealed disaster drills were conducted and documented as follows: - March 16, 2023 at 11:20 AM on the 8 AM to 4 PM shift; - December 2, 2022 at 8:30 PM on an 8 PM to 8 AM shift; - September 1, 2022 at 9 AM on the 8 AM to 8 PM shift; and - June 1, 2022 at 8:35 PM on the 8 PM to 8 AM shift. 4. In an interview, E1 and E3 acknowledged disaster drills were not conducted and documented on each shift at least once every three months.

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

evidence: Based on documentation review and interview, the administrator failed to ensure an evacuation drill for employees and residents was conducted at least once every six months on each shift.

findings: 1. A review of facility documentation revealed a work schedule indicating the facility worked on three shifts, from 8 AM to 4 PM, from 4PM to 12 AM, and from 12 AM to 8 AM. 2. In an interview, E1 reported the shift pattern has altered with staffing levels and the facility was on two shifts before starting the current three shift pattern. 3. A review of facility documentation from the previous twelve months revealed evacuation drills were conducted and documented as follows: - March 24, 2023 at 10:15 AM on an 8 AM to 8 PM shift; - November 20, 2022 at 8:25 PM on an 8 PM to 8 AM shift; and - June 3, 2022 at 9:20 AM on an 8 AM to 8 PM shift. 4. In an interview, E1 acknowledged evacuation drills for employees and residents were not conducted every six months on each shift.

rule: 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 in a locked area separate from food preparation areas and inaccessible to residents.

findings: 1. During a facility tour, the Compliance Officer observed a cabinet in the kitchen area did not have a lock, was used to store food preparation materials such as pots and pans, and was accessible to residents. Inside the cabinet, the Compliance Officer observed a spray bottle of, "Windex." 2. In an interview, E1 acknowledged poisonous of toxic materials were not in a locked area inaccessible to residents.


summary: Complaint - 4/18/2023

raw_content: An on-site investigation of complaints AZ00192918 and AZ00194002 was conducted on April 18, 2023, and the following deficiencies were cited :

evidence: Based on observation, documentation review, and interview, the administrator failed to ensure a daily staffing schedule included documentation of the employees who work each calendar day and the hours worked by each employee.

findings: 1. Upon arriving at the facility, the Compliance Officer observed E1, E2, E6, E10, and E11 were present at the facility. 2. A documentation review of the facility staffing schedule for the month of April 2023, revealed a schedule dated, "April 1 thru April 30." The schedule included the date, scheduled work hours, and initials of each employee assigned to work. However, the schedule did not include the documentation of the hours worked by each employee who worked on each calendar day: - The schedule stated, "[E9] start on April 17." However, the schedule did not include documentation of the hours worked by E9 on April 17. - The schedule stated, "[E2] or [E1]..3rd. 11-8A on every day of the month. However, the schedule did not indicate which employee was working on any given night. - The work schedule did not document any on-site hours for the faclity's behavioral health professional or registered nurse during the month of April 2023. - The work schedule did not include any udpates when a scheduled employee did not work their scheduled hours or when an on-call personnel member was called in and worked the facility. 3. In an interview, E6 reported E1 or E2 each work different nights and one of them is always at the facility overnight. E6 acknowledged the schedule did not indicate what days E1 or E2 worked at the facility. E6 reported when on-call personnel are present at the facility or when scheduled personnel do not work their scheduled hours, the schedule is not updated to reflect the actual hours worked by each employee. 4. In an interview, E1 acknowledged the work schedule represented the planned shifts and did not include documentation of the employees who actually worked each calendar day. E1 reported E1 and E2 worked long hours at the facility but were only scheduled to work overnight until additional staff could be hired to fill the overnight spots. E1 acknowledged E1's and E2's actual work hours had not been documented on the schedule. Technical Assistance for this rule was provided during the on-site complaint inspection conducted on March 2, 2023.

rule: B. An administrator shall ensure that: 2. A resident is not subjected to: m. Treatment that involves the denial of: i. Food,

evidence: Based on documentation review and interview, the administrator failed to ensure a resident was not subjected to treatment involving the denial of food. R9-10-101(238) states: "Treatment" means a procedure or method to cure, improve, or palliate an individual ' s medical condition or behavioral health issue.

findings: 1. A review of facility documentation revealed an incident report dated April 9, 2023 at 8:15 a.m. The incident report was generated by E3. The incident report stated, On 4/9/23, [R1] came to the office saying, "I want some breakfast." [E3] asked if [R1's] chores were done. Another staff member said, 'I did [R1's] last night." [E3] told [R1] to vacuum the church. [R1] said, 'fuck that, it's not my chore.' [R1] asked for breakfast again. [E3] asked, 'is the church vacced?' [R1] stated, 'that's a bitch move not giving me breakfast for not cleaning that.' 2. A review of the facility's policies and procedures revealed a policy titled, "Resident Rights." The policy stated, "...B. An administrator shall ensure that:... 2. A resident is not subjected to:... m. Treatment that involves the denial of: i. food." 3. In an interview with E1 and E3, E3 reported R1 did eat breakfast after R1 did the chores. E3 reported when E3 was hired, E3 was told by other staff that the chores must be finished prior to breakfast. 4. In an interview, E1 reported as part of the treatment at the facility, there is a daily schedule which includes meals, counseling, activities, school, chores, and other parts of the daily routine. E1 reported the schedule includes a chore each resident is asked to complete prior to breakfast at 8 a.m. However, E1 reported the consequence for not completing a chore was not supposed to involve denial of the meal. E1 acknowledged the incident report and interview with E3 indicated a meal had been denied temporarily due to a resident not complying with the daily treatment schedule.


facility_name: A CARING COMMUNITY LLC

summary: Complaint - 11/6/2025

raw_content:
An on-site complaint investigation of complaint 00149090 was conducted on November 6, 2025.

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


summary: Complaint - 4/14/2025

raw_content: An on-site investigation of complaint 00126224 was conducted on April 14, 2025 and no deficiencies were cited.


summary: Complaint - 2/4/2025

raw_content: The following deficiencies were found during the on-site complaint investigation of AZ00222964 conducted on February 4, 2025:

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: 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 skills and knowledge necessary to ensure the health and safety of a resident. The deficient practice posed a risk as restraints are not authorized in a behavioral health residential facilty, E2 was trained in CPT and restrained a resident, and the repeated violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: R9-10-101(201) "'Restraint" means any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body. R9-10-701. "Emergency safety response" means physically holding a resident to manage the resident ' s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. 1. A review of facility documentation revealed a policy and procedure, date unknown, titled "EMERGENCY SAFETY RESPONSE." The policy stated "ACC will not employ Emergency Safety Response. "Emergency safety response" means physically holding a resident to safely manage a sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Our staff is thoroughly trained to manage behaviors via verbal redirection, de-escalation, and therapeutic holds as derived from the Handle with Care Behavior Management Program or CPI." 2. A review of facility documentation revealed security camera footage dated February 1, 2025 at 10:38 P.M. R1 was seen attempting to grab E2's necklace. E2 was seen placing both hands around R1's wrists and E2 walked forward forcing R1 to walk backwards until reaching the hallway wall. E2 appeared to engage in "horse play" with residents throughout multiple security camera footage reviews. 3. A review of facility documentation revealed an incident report dated February 3, 2025, completed by E1. The incident report stated "[R1] engaged in boundary-testing behavior by reaching into [E2's] personal space and attempting to grasp [E2's] necklace. In response, staff implemented non-invasive redirection by positioning their forearm as a barrier and gently removing [R1's] hand. Despite multiple redirections, [R1] continued the behavior, requiring staff to guide [R1's] hands away until [R1] ceased the attempts." 4. A review of E2's (hired in June 2022) personnel record revealed documentation of E2's completed emergency safety response (ESR) training, dated April 22, 2024. E2's certificate stated "SontarahLife Certificate of Completion This is to verify that [E2] Has successfully completed a Crisis Prevention and Intervention Level 2 with all de-escalation methods including proper restraints [sic] certified course provided by the above agency..." 5. In an interview, E1 reported E2 followed proper training based off the training received from the aforementioned course. E1 acknowledged the definition of restraint as defined in Article 1. E1 stated E2 was a "big brother or uncle" figure to the residents and often engaged in "horse play." E1 acknowledged E2 failed to maintain professional boundaries with residents. E1 acknowledged the aforementioned security camera footage showed E2 wrapping E2's hands around R1's wrists. E1 acknowledged E2 restricted R1's freedom of movement, physical activity or access to R1's body. E1 acknowledged residents have the right not to be restrained and restraints are not allowed at a behavioral health residential facility. E1 acknowledged E2 was not sufficient to protect R1's health and safety. E1 acknowledged Level 2 training was not appropriate. 6. In an exit interview, the findings were discussed with E1 and no additional statement or documentation were provided. This Rule was cited on August 28, 2024. A letter, sent to the licensee on September 13, 2024, stated "the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD."

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 compliance with A.R.S. \'a7\'a7 36-425.03(E), for five of five personnel members sampled. The deficient practice posed a risk as the repeated deficiency violation shows a pattern of noncompliance to ensure the health and safety of residents.

findings: A.R.S. \'a7\'a7 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." 1. A review of E2's (hired June 2022) personnel record revealed E2's "Criminal History Self Disclosure Affidavit" from the Arizona Department of Child Safety. However, E2's documentation in compliance with A.R.S. \'a7 36-425.03(E) on a form provided by the Department was not available for review. 2. A review of E3's (hired November 2024) personnel record revealed E3's "Criminal History Self Disclosure Affidavit" from the Arizona Department of Economic Security. However, E3's documentation in compliance with A.R.S. \'a7 36-425.03(E) on a form provided by the Department was not available for review. 3. A review of E4's (hired July 2021) personnel record revealed E4's "Criminal History Self Disclosure Affidavit" from the Arizona Department of Child Safety. However, E4's documentation in compliance with A.R.S. \'a7 36-425.03(E) on a form provided by the Department was not available for review. 4. A review of E5's (hired August 2021) personnel record revealed E5's "Criminal History Self Disclosure Affidavit" from the Arizona Department of Economic Security. However, E5's documentation in compliance with A.R.S. \'a7 36-425.03(E) on a form provided by the Department was not available for review. 5. A review of E6's (hired March 2024) personnel record revealed E6's "Criminal History Self Disclosure Affidavit" from the Arizona Department of Economic Security. However, E6's documentation in compliance with A.R.S. \'a7 36-425.03(E) on a form provided by the Department was not available for review. 6. In an interview, E1 acknowledged personnel member's documentation in compliance with A.R.S. \'a7 36-425.03(E) were not on forms provided by the Department. E1 reported E1 was unaware of the requirement to use the form provided by the Department. E1 acknowledged where to locate the form in compliance with A.R.S. \'a7 36-425.03(E) on the Department's website. 7. In an exit interview, the findings were discussed with E1 and no additional statement or documentation were provided. This is a repeat violation from the compliance inspection conducted on May 20, 2024. This is a repeat violation from the complaint investigation conducted on June 22, 2023. This is a repeat violation from the compliance inspection conducted on February 24, 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: 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. \'a7 8-804(C), for five of five personnel members sampled. The deficient practice posed a risk if the personnel members were a danger to a vulnerable population.

findings: A.R.S. \'a7 8-804(C) states "Licensees that do not contract with the state and that employ persons who provide direct services to children pursuant to title 36, chapter 7.1 must submit to the department of child safety in a manner prescribed by the department of child safety information necessary to conduct central registry background checks. The department of health services shall verify whether licensees, pursuant to title 36, chapter 7.1, have complied with the requirements of this subsection and any rules adopted by the department of health services to implement this subsection." 1. A review of E2's (hired June 2022) personnel record revealed E2's was hired as a behavioral health technician (BHT). However, 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 not available for review. 2. A review of E3's (hired November 2024) personnel record revealed E3's was hired as a BHT. However, 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 E3 was not available for review. 3. A review of E4's (hired July 2021) personnel record revealed E4's was hired as a BHT. However, 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 not available for review. 4. A review of E5's (hired August 2021) personnel record revealed E5's was hired as a BHT. However, 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 E5 was not available for review. 5. A review of E6's (hired March 2024) personnel record revealed E6's was hired as a BHT. However, 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 E6 was not available for review. 6. In an interview, E1 acknowledged E1 was required to submit documentation to the department of child safety in a manner prescribed by the department of child safety to conduct a central registry background check on all personnel members. E1 reported E1 was unaware of this requirement. 7. In an exit interview, the findings were discussed with E1 and no additional statements or documentation were provided.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as restraints are not authorized in a behavioral health residential facilty, and E2 restrained a resident.

findings: R9-10-101(201) "Restraint" means any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body. 1. A review of facility documentation revealed a policy and procedure, date unknown, titled "EMERGENCY SAFETY RESPONSE." The policy stated "ACC will not employ Emergency Safety Response. "Emergency safety response" means physically holding a resident to safely manage a sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Our staff is thoroughly trained to manage behaviors via verbal redirection, de-escalation, and therapeutic holds as derived from the Handle with Care Behavior Management Program or CPI." 2. A review of facility documentation revealed security camera footage dated February 1, 2025 at 10:38 P.M. R1 was seen attempting to grab E2's necklace. E2 was seen placing both hands around R1's wrists and E2 walked forward forcing R1 to walk backwards until reaching the hallway wall. E2 appeared to engage in "horse play" with residents throughout multiple security camera footage reviews. 3. A review of facility documentation revealed an incident report dated February 3, 2025, completed by E1. The incident report stated "[R1] engaged in boundary-testing behavior by reaching into [E2's] personal space and attempting to grasp [E2's] necklace. In response, staff implemented non-invasive redirection by positioning their forearm as a barrier and gently removing [R1's] hand. Despite multiple redirections, [R1] continued the behavior, requiring staff to guide [R1] hands away until [R1] ceased the attempts." 4. A review of E2's (hired in June 2022) personnel record revealed documentation of E2's completed emergency safety response (ESR) training, April 22, 2024. E2's certificate stated "SontarahLife Certificate of Completion This is to verify that [E2] Has successfully completed a Crisis Prevention and Intervention Level 2 with all de-escalation methods including proper restraints certified course provided by the above agency..." 5. In an interview, E1 reported E2 followed proper training based off the training received from the aforementioned course. E1 acknowledged the definition of restraint as defined in Article 1. E1 stated E2 was a "big brother or uncle" figure to the residents and often engaged in "horse play." E1 acknowledged E2 failed to maintain professional boundaries with residents. E1 acknowledged the aforementioned security camera footage showed E2 wrapping E2's hands around R1's wrists. E1 acknowledged E2 restricted R1's freedom of movement, physical activity or access to R1's body. E1 acknowledged residents have the right not to be restrained and restraints are not allowed at a behavioral health residential facility. E1 acknowledged R1 was not treated with dignity, respect, or consideration. 6. In an exit interview, the findings were discussed with E1 and no additional statement or documentation were provided. This Rule was cited on August 28, 2024. A letter, sent to the licensee on September 13, 2024, stated "the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD. "

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a resident was not subjected to restraint. The deficient practice posed a risk as restraints are not authorized in a behavioral health residential facilty, and E2 restrained a resident.

findings: R9-10-101(201) "Restraint" means any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body. 1. A review of facility documentation revealed a policy and procedure, date unknown, titled "EMERGENCY SAFETY RESPONSE." The policy stated "ACC will not employ Emergency Safety Response. "Emergency safety response" means physically holding a resident to safely manage a sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Our staff is thoroughly trained to manage behaviors via verbal redirection, de-escalation, and therapeutic holds as derived from the Handle with Care Behavior Management Program or CPI." 2. A review of facility documentation revealed security camera footage dated February 1, 2025 at 10:38 P.M. R1 was seen attempting to grab E2's necklace. E2 was seen placing both hands around R1's wrists and E2 walked forward forcing R1 to walk backwards until reaching the hallway wall. E2 appeared to engage in "horse play" with residents throughout multiple security camera footage reviews. 3. A review of facility documentation revealed an incident report dated February 3, 2025, completed by E1. The incident report stated "[R1] engaged in boundary-testing behavior by reaching into [E2's] personal space and attempting to grasp [E2's] necklace. In response, staff implemented non-invasive redirection by positioning their forearm as a barrier and gently removing [R1's] hand. Despite multiple redirections, [R1] continued the behavior, requiring staff to guide [R1] hands away until [R1] ceased the attempts." 4. A review of E2's (hired in June 2022) personnel record revealed documentation of E2's completed emergency safety response (ESR) training, dated April 22, 2024. E2's certificate stated "SontarahLife Certificate of Completion This is to verify that [E2] Has successfully completed a Crisis Prevention and Intervention Level 2 with all de-escalation methods including proper restraints certified course provided by the above agency..." 5. In an interview, E1 reported E2 followed proper training based off the training received from the aforementioned course. E1 acknowledged the definition of restraint as defined in Article 1. E1 stated E2 was a "big brother or uncle" figure to the residents and often engaged in "horse play." E1 acknowledged E2 failed to maintain professional boundaries with residents. E1 acknowledged the aforementioned security camera footage showed E2 wrapping E2's hands around R1's wrists. E1 acknowledged E2 restricted R1's freedom of movement, physical activity or access to R1's body. E1 acknowledged residents have the right not to be restrained and restraints are not allowed at a behavioral health residential facility. 6. In an exit interview, the findings were discussed with E1 and no additional statement or documentation were provided. This Rule was cited on August 28, 2024. A letter, sent to the facility on September 13, 2024, stated "the Department requires that you make immediate corrections of violations that present a threat to the health or safety of a client, resident, patient or agency personnel and still requires that you make corrections to all violations noted in the SOD."


summary: Complaint - 11/21/2024

raw_content: An on-site investigation of complaint AZ00219052 was conducted on November 21, 2024 and no deficiencies were cited.