summary: Compliance (Annual) - 6/19/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on June 19, 2023:

inspection_type: Compliance (Annual)

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

evidence: Based on record review, documentation review and interview, the residential care institution failed to ensure compliance with A.R.S. \'a7 36-411(A), for one of six personnel members sampled. The deficient practice posed a risk if E6 was a danger to a vulnerable population.

findings: 1. A review of E6's (hired in 2019) personnel record revealed a fingerprint clearance card, issued on July 26, 2016 and expired on July 26, 2022. However, documentation of a valid fingerprint clearance card was not available for review. 2. A review of the Arizona Department of Public Safety (DPS) fingerprint verification website revealed E6's card was issued on July 26, 2016 and expired on July 26, 2022. 3. A review of the Arizona Department of Public Safety (DPS) fingerprint verification website revealed E6 applied for a new fingerprint clearance card on April 22, 2022. However, the status was "closed." 4. In an interview, E1 acknowledged E6's fingerprint clearance card had expired. E1 reported to be unaware E6 needed a new fingerprint clearance card since E6 lived in another state and did not come to the facility to provide services.

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

evidence: Based on documentation review, record review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery.

findings: 1. A review of facility documentation revealed a training program for fall prevention and fall recovery was not available for review. 2. A review of E1's, E2's, E3's, E5's and E6's personnel records revealed initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged a training program for fall prevention and fall recovery training was not available for review. E2 reported to be unaware of the requirement.

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

evidence: Based on documentation review and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the administrator and identify the name and qualifications of the new administrator.

findings: 1. A review of Department documentation revealed E7 was the facility's administrator during the on-site inspections conducted on May 31, 2022 and on November 10, 2022. 2. In an interview, E1 reported E8 was the facility's administrator. E1 stated E8 had been the administrator "for a good while." E1 reported to be unsure if anyone from the facility ever submitted documentation to the Department to notify the Department of the administrator change. E1 acknowledged E1 was unable to provide any documentation showing the Department was notified when E8 became the administrator.

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 record review, documentation review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include documentation of cardiopulmonary resuscitation (CPR) training, for one of six personnel members sampled. The deficient practice posed a risk if a personnel member was unable to perform CPR.

findings: 1. A review of E2's personnel record revealed documentation of first aid and CPR training, dated February 22. 2023. However, the first aid and CPR training card was from an online program. 2. A review of facility documentation revealed a daily staffing schedule, dated "Mon 6/19 - Sun 6/25." The schedule revealed E2 worked the following shifts: -Monday June 19 - 11:00 PM - 8:00 AM -Tuesday June 20 - 11:00 PM - 8:00 AM -Wednesday June 21 - 11:00 PM - 8:00 AM -Thursday June 22 - 11:00 PM - 8:00 AM 3. A review of the facility's policies and procedure, dated May 25, 2023, revealed a policy titled, "Personnel Training." The policy stated, "b. No online training will be acceptable. All CPR training must be completed in person." 4. In an interview, E1 acknowledged E2's CPR training had been completed online and did not include a demonstration.

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure at least one personnel member present at the behavioral health facility during hours of operation had cardiopulmonary resuscitation (CPR) training, for one of two behavioral health technicians sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency, accident, or injury.

findings: 1. A review of the facility's policies and procedure, dated May 25, 2023, revealed a policy titled, "Personnel Training." The policy stated, "II. Policy: A. Cardiopulmonary Resuscitation (CPR)a. All staff members shall complete and have documentation of the completion of a nationally recognized Cardio-Pulmonary Resuscitation (CPR) class. b. No online training will be acceptable. All CPR training must be completed in person.c. Training must be completed every 2 years." 2. A review of facility documentation revealed a daily staffing schedule, dated "Mon 6/19 - Sun 6/25." The schedule revealed E2 worked the following shifts alone: -Monday June 19 - 11:00 PM - 8:00 AM -Tuesday June 20 - 11:00 PM - 8:00 AM -Wednesday June 21 - 11:00 PM - 8:00 AM -Thursday June 22 - 11:00 PM - 8:00 AM 3. A review of E2's personnel record revealed documentation of first aid and CPR training, dated February 22, 2023. However, the CPR training card was from an online program. 4. In an interview, E1 acknowledged E2's CPR training card was from an online program. E1 acknowledged E2 worked shifts at the facility alone.

rule: A. An administrator shall ensure that: 6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission;

evidence: Based on record review and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission, for one of two residents sampled. The deficient practice posed a risk as this information was required for the development and implementation of a treatment plan, per R9-10-708.A.1.

findings: 1. A review of R1's (admitted in 2023) medical record revealed a nursing assessment was completed on January 31, 2023. However, the nursing assessment was not completed within 30 calendar days before admission or within 72 hours after admission. 2. In an interview, E1 acknowledged R1's nursing assessment was not completed within 30 calendar days before admission or within 72 hours after admission.

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) was reviewed and signed by the behavioral health professional (BHP) within 24 hours, for one of two residents sampled.

findings: 1. A review of R1's (admitted in 2023) medical record revealed an undated "Client Intake Assessment Packet. " However, the document did not contain a signature of who conducted the assessment, and did not contain a signature and date from a BHP who reviewed the behavioral health assessment. 2. In an interview, E1 acknowledged the BHP did not review and sign the behavioral health assessment for R1 within 24 hours. E1 reported R1's assessment was completed by E2, a BHT.

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 resident sampled who was admitted in 2023. The deficient practice posed a TB exposure risk to residents. Findings: 1. A review of R1's (admitted in 2023) medical record revealed evidence of freedom from infectious TB was not available for review. Based on R1's date of admission, the evidence was required. 2. In an interview, E1 acknowledged R1's medical record did not provide evidence of freedom from infectious TB before or within seven calendar days after R1's admission.

rule: B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 2. The disaster plan required in subsection (B)(1) is reviewed at least once every 12 months;

evidence: Based on documentation review and interview, the administrator failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a plan reinforces and clarifies standards expected of employees.

findings: 1. A review of Department documentation revealed the license for BH6115 was effective May 11, 2020. 2. A review of facility documentation revealed an undated disaster plan. However, an annual review of the disaster plan was not available for review. 3. In an interview, E1 acknowledged the facility had not reviewed the disaster plan in the last 12 months.

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. The deficient practice posed a risk if employees were unable to implement a disaster plan.

findings: 1. A review of Department documention revealed the license for BH6115 was effective on May 11, 2020. 2. A review of a daily staffing schedule dated "Mon 6/19 - Sun 6/25" revealed the facility maintained three shifts: 7:00 AM to 1:00 PM (first), 1:00 PM to 11:00 PM (second) and 11:00 PM to 8:00 AM (varied hours range from 7:00 AM to 8:00 AM on different days.) 3. A review of facility documentation revealed disaster drills were not available for review. 4. In an interview, E1 reported the facility maintained three shifts that varied from times, based on personnel availability. E1 acknowledged disaster drills were not conducted on each shift at least once every three months. Technical assistance was provided on this Rule during the onsite compliance inspection conducted on May 31, 2022 and this Rule was cited durin the onsite compliance inspection conducted on April 30, 2021.

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 on the premises was conducted at least once every six months on each shift. The deficient practice posed a risk if employees were unable to implement a disaster plan, and the Department was unable to determine substantial compliance during the inspection.

findings: 1. A review of Department documention revealed the license for BH6115 was effective on May 11, 2020. 2. A review of a daily staffing schedule dated "Mon 6/19 - Sun 6/25" revealed the facility maintained three shifts: 7:00 AM to 1:00 PM (first), 1:00 PM to 11:00 PM (second) and 11:00 PM to 8:00 AM (varied hours range from 7:00 AM to 8:00 AM on different days.) 3. A review of facility documentation revealed the following evacuation drills were completed: -May 26, 2022 - 1st shift -November 8, 2022 - 3rd shift -November 9, 2022 - 2nd shift -November 10, 2022 - 3rd shift -May 12, 2023 - 3rd shift 4. In an interview, E1 reported the facility maintained three shifts that varied from times, based on personnel availability. E1 acknowledged evacuation drills had not been conducted at least once 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: 10. Hot water temperatures are maintained between 95° F and 120° F in the areas of the behavioral health residential facility used by residents;

evidence: Based on observation and interview, the administrator failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of the behavioral health residential facility used by residents. The deficient practice posed a burn risk to residents.

findings: 1. The Compliance Officer observed the hot water temperature at the kitchen sink to be 133.7\'b0 F using a Department-issued thermometer. 2. The Compliance Officer observed the hot water temperature at the hallway bathroom sink to be 138.7\'b0 F using a Department-issued thermometer. 3. In an interview, E1 acknowledged the temperature of the hot water in the facility was not maintained between 95\'b0 F and 120\'b0 F.


state: AZ

facility_name: MISS A'S, LLC

summary: Complaint - 2/5/2026

raw_content: The following deficiency was found during the on-site  investigation of complaint 00158051 conducted on February 5, 2026:

inspection_type: Complaint

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

evidence: Based on record review, documentation review and interview, the administrator failed to ensure a resident did not have access to any materials that may present a threat to the resident's health or safety based on the residents treatment needs and personal history. The deficient practice posed a risk as R1 gained access to alcohol while admitted into a behavioral health residential facility for individuals under 18 years of age.

findings: R9-10-101.32.“Behavioral health issue” means an individual’s condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. R9-10-101.36. “Behavioral health residential facility” means a health care institution that provides treatment to an individual experiencing a behavioral health issue that: a. Limits the individual’s ability to be independent, or b. Causes the individual to require treatment to maintain or enhance independence. 1. A review of R1's medical record revealed R1 had a history of substance use. 2. A review of R1's medical record revealed a document titled "Incident Report Form" dated in January 2026. The document stated, "At approximately 10:00PM, member's peer reported that member was presenting with symptoms of intoxication. When observed, member did not present with any concerns regarding intoxication or suspected intoxication; however, member was given a breathalyzer which came back with a 0.17 BAC. Member was questioned regarding the incident and interviewed regarding where member had gotten the alcohol from a peer who had gone AWOL recently. Member was again given a breathalyzer approximate 1 hour later which showed 0.11 BAC. Member informed staff through investigation that member had drank the alcohol that a peer had given him from a recent AWOL and threw the 2 small empty "shooters" over the wall of the back yard. When staff searched this area, the empty bottles were found and disposed of. Staff interviewed and questioned peers to verify member's reports which all indicated member's reports were validated." 3. In an exit interview, the findings were reviewed with E1, and no additional statements or documentation were provided.


summary: Complaint;Compliance (Annual) - 10/23/2025

raw_content: No deficiencies were found during the on-site compliance inspection and investigation of complaints 00136908 and 00148416 conducted on October 23, 2025.

inspection_type: Complaint;Compliance (Annual)


summary: Complaint - 3/21/2025

raw_content: An on-site investigation of complaint 00123321 was conducted on March 21, 2025 and the following deficiencies were cited:

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

evidence: Based on documentation review, record review, and interview, the administrator failed to implement policies and procedures to protect the health and safety of a resident to cover administering medication. The deficient practice posed a risk as standards expected of employees were not followed.

findings: R9-10-101.136. “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 facility documentation revealed a policy and procedure, dated April 2024, titled “Medication Errors.” The policy stated “In the event that staff mistakenly administers a medication improperly or at an improper time, the staff member indicates on the medication administration record the mistake, who was notified, and the outcome. Staff will also complete the medication error form to keep an accurate count of medication, and file in the member medical record…” 2. A review of R1’s (admitted in October 2024) medical record revealed R1’s medication order dated in January 2025. R1’s orders stated “Sertraline…25 MG…1x Daily… 7AM…” 3. A review of facility documentation revealed a binder which contained medication administration records (MAR) for residents. R1's MAR for January 2025 through March 2025 revealed medication administered more than sixty minutes after 7 AM on the following dates: January 13, 18, 19, 28, 2025; February 2, 9, 16, 2025; and March 9, 10, 15, 16, 2025 4. A review of R1’s medical record revealed medication error forms were not available for review. 5. In a joint interview, E2 reported the aforementioned medication administrations were administered after the ordered time of 7:00 A.M. E1 and E2 acknowledged the medication administration records did not contain notes on each administration documenting the medication was administered more than sixty minutes after the ordered time of administration. E1 and E2 acknowledged the medication error policy and procedure was not implemented on the aforementioned dates. 6. In an exit interview, the findings were discussed with E1 and E2 and no additional statements or documentation were provided.

evidence: Based on record review and interview, the administrator failed to ensure a resident did not have access to any materials that may cause a threat to the residents’ health or safety based on the resident’s documented diagnosis. The deficient practice posed a risk as R1 had access to marijuana while admitted in to a behavioral health residential facility.

findings: 1. A review of R1’s (admitted in October 2024) medical record revealed a document titled “Medical FaceSheet.” R1’s face sheet stated “Diagnosis…Cannabis dependence, uncomplicated…” 2. A review of R1’s medical record revealed a urinary analysis test (dated in February 2025) with a preliminary positive reading for tetrahydrocannabinol (THC). 3. A review of facility documentation revealed an email, dated in February 2025, from E2 to R1’s clinical team. The email stated “Over the weekend we discovered that some of [R2’s] belongings were gathered and taken to school to sale/trade for a vape. The peer who attends in person school is the peer [R1] has engaged in negative choices with and at this time is alleged to have helped assist in gathering the peer’s items. With this knowledge we tested [R1] today and [R1] was positive for THC…” 4. In an interview, E2 reported R2 repeatedly traded and obtained marijuana vape pens and had repetitive positive urinary analysis tests for marijuana. 5. In a joint interview, E1 and E2 reported personnel members search each resident when they return to the facility. E1 and E2 reported personnel members found a marijuana vape pen in the hallway bathroom. E1 and E2 reported R1 and R2 did not share a room and were not observed with the vape pen. E1 and E2 reported the facility searched residents as in depth as possible and residents were always under supervision. E1 and E2 acknowledged R1 had access to a marijuana. 6. In an exit interview, the findings were discussed with E1 and E2 and no additional statements or documentation were provided.

rule: R9-10-718.B.3.a-b. Medication Services 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 b. Is documented in the resident's medical record.

evidence: Based on record review, documentation review, and interview, the administrator failed to ensure medication administration was provided to a resident in compliance with an order. The deficient practice posed a risk if R1 experienced a change in condition due to improper medication administration.

findings: 1. A review of R1’s (admitted in October 2024) medical record revealed R1’s medication order dated in January 2025. R1’s orders stated “Sertraline…25 MG…1x Daily… 7AM…” 2. A review of facility documentation revealed a binder which contained medication administration records (MAR) for residents. R1's MAR for January 2025 through March 2025 revealed medication administered more than sixty minutes after 7 AM on the following dates: January 13, 18, 19, 28, 2025; February 2, 9, 16, 2025; and March 9, 10, 15, 16, 2025 4. A review of R1’s medical record revealed medication error documentation was not available for review. 5. In a joint interview, E2 reported the aforementioned medication administrations were administered after the ordered time of 7:00 A.M. E1 and E2 acknowledged the medication administration records did not contain documentation showing the information required information. E1 and E2 acknowledged R1’s Sertraline was not administered in compliance with an order. 6. In an exit interview, the findings were discussed with E1 and E2 and no additional statements or documentation were provided.


summary: Compliance (Annual) - 1/13/2025

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on January 13, 2025:

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, documentation review, record 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 E5 was not designated to act on behalf of the governing authority when E1 was not present on the behavioral health residential facility's premises.

findings: 1. The Compliance Officer observed E5 on the premises and working alone when the Compliance Officer arrived at 8:20AM. 2. The Compliance Officer observed six residents on the premises. 3. The Compliance Officer observed E1 arrive on the premises at approximately 8:45AM. 4. A review of facility documentation revealed documentation to designate an individual who was present on the behavioral health residential facility's premises and accountable for the behavioral health facility when the administrator was not present on the premises was not available for review. 5. A review of E5's (hired in 2024) personnel record revealed E5 was hired as a behavioral health technician (BHT). However, documentation designating E5 to be present on the behavioral health residential facility's premises and accountable for the behavioral health facility when E1 was not present on the premises was not available for review. 6. In an interview, E1 reported documentation to designate E5 to be present on the behavioral health residential facility's premises and accountable for the behavioral health facility when the administrator was not present was not available for review. E1 reported E1 was unaware of the requirement. 7.In an exit interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

rule: F. An administrator shall ensure that a personnel member, or an employee, a volunteer, or a student who has or is expected to have more than eight hours of direct interaction per week with residents, provides evidence of freedom from infectious tuberculosis: 1. On or before the date the individual begins providing services at or on behalf of the behavioral health residential facility, and 2. As specified in R9-10-113.

evidence: Based on record review and interview, the administrator failed to ensure a personnel member provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the behavioral health residential facility, for one of seven personnel members sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: 1. A review of E5's (hired in 2024) personnel record revealed E5 was hired as a behavioral health technician (BHT). E5's personnel record revealed documentation of evidence of freedom from infectious TB dated approximately 49 days after E5's starting date of employment. 2. In an exit interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

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 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 (CPR) training specific to the populations served by the behavioral health residential facility. The deficient practice posed a risk if E6 was unable to meet a resident's needs during an emergency or during an accident.

findings: 1. A review of facility documentation revealed a policy and procedure titled "CPR and First Aid; R9-10-703.C.1.e and R9-10-706.1" (dated in August 19, 2024). The policy and procedure stated "... Behavioral Health Technicians associated to Miss A's, will have the required cardiopulmonary resuscitation, (CPR) and first aid training that includes a demonstration during employee orientation of hands on training ... Ensure class was a hands-on training ... View demonstration of the CPR will be performed ensuring knowledge and ability." 2. A review of facility documentation revealed a daily staffing schedule for January 11-17, 2025. The schedule revealed E6 was scheduled to work alone from 10:00PM to 6:00AM on January 12, 2025 and January 17, 2025. 3. A review of E6's (hired in 2024) personnel record revealed E6 was hired as a behavioral health technician (BHT). The personnel record revealed a document titled "HSI CPR AED All Ages (2020) - (Blended) - DC" (dated December 17, 2023). The document stated "[E6] has successfully completed HSI online training ... Completion Date: 09/12/2024" and "Blended learning consists of computer-based, online lessons, combined with hands-on skill practice and performance evaluation. This document confirms that the above-named individual has completed the required online lessons and is now eligible for hands-on skill and practice and performance evaluation by a current and properly authorized HSI Instructor." However, documentation of CPR training with demonstration was not available for review. 4. In an exit interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

rule: A. Except for a behavioral health outdoor program, an administrator shall ensure that the premises and equipment are sufficient to accommodate: 1. The services in the behavioral health residential facility's scope of services, and

evidence: Based on documentation review, observation, and interview, the administrator failed to ensure the premises were sufficient to accommodate the behavioral health services in the facility's scope of services.

findings: R9-10-101.52.a."Common area" means licensed space in health care institution that is not a resident ' s bedroom or a residential unit R9-10-722.B.1.a. An administrator shall ensure that: 1. A behavioral health residential facility has a room that provides privacy for a resident to receive treatment or visitors R9-10-722.B.8.a. A resident bedroom complies with the following is not used as a common area; 1. A review of Department documentation revealed BH6116 was licensed for eight residents effective March 12, 2020. 2. The Compliance Officer observed the behavioral health residential facility had room to provide privacy for a resident to receive treatment or visitors. The Compliance Officer observed the room was also used as an office. The Compliance Officer observed two chairs, a large corner desk, a table with a large printer on top, and two large cabinets. 3. A review of facility documentation revealed a scope of services (dated August 19, 2024). The scope of services stated "The scope of services stated " ... Counseling - Individual, Group and Family." 4. In an interview, E6 reported individual counseling was conducted in the residents' bedrooms and group counseling was conducted in the facility's second floor loft. 5. The Compliance Officer observed the facility's second floor loft had couches and chairs. However, the loft did not provide privacy in treatment. 6. In an interview, E1 reported individual counseling was conducted in the residents' bedrooms and group counseling was conducted in the facility's second floor loft. 7. In an exit interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.


summary: Compliance (Annual) - 2/13/2024

raw_content: The following deficiency was found during the on-site compliance inspection conducted on February 13, 2024:

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 observation 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: R9-10-720.C.3. An administrator shall maintain documentation of a current fire inspection. 1. The Compliance Officer requested to review the facility's current fire inspection. However, a current fire inspection report was not provided for review within two hours after a Department request. 2. In an interview, E1 reported the facility had a current fire inspection and E1 reported to be unable to locate the documentation. E1 acknowledged a current fire inspection report was not provided for review within two hours after a Department request.


facility_name: GOLDEN HEART CARE

summary: Compliance (Annual) - 1/28/2026

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on January 28, 2026.

rule: R9-10-706.F.2. Personnel F. An administrator shall ensure that a personnel member, or an employee, a volunteer, or a student who has or is expected to have more than eight hours of direct interaction per week with residents, provides evidence of freedom from infectious tuberculosis: 2. As specified in R9-10-113.

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 R9-10-113, for two of four personnel members sampled. The deficient practice posed a health and safety risk for a potential TB exposure risk to residents.

findings: 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). A.A.C. R9-10-113(B)(1)(a)(i)(ii) 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 specific 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); i. Was administered within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution. 1. A review of E4's personnel record revealed documentation of the individual's freedom from infectious TB. However, E6's personnel record revealed no documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, and determining if the individual had signs or symptoms of TB 2. A review of E5's personnel record revealed revealed no documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB. 3. In an interview, E1 reported E1 believed E5 had TB tests, however, E1 could not locate the documentation. E1 reported E4 and E5 did not complete baseline screening consisting of assessing risks of prior exposure to infectious TB, and determining if the individuals had signs or symptoms of TB. 4. In an exit interview, the findings were reviewed with E1, and no statements or documentation were provided. This is a repeat deficiency from an inspection conducted on February 19, 2025.

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, 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 first-aid and cardiopulmonary resuscitation (CPR) training specific to the populations served by the behavioral health residential facility, for one of four personnel members sampled. The deficient practice posed a health and safety risk if E4 were unable to meet a resident's needs during an accident or emergency.

findings: 1. The Compliance Officer observed E4 to be the only staff member working on-site. 2. A review of facility documentation revealed a staffing schedule for the month of January 2026, The schedule was dated for Monday through Sunday, and did not include individual dates. The staffing schedule revealed E4 was the only staff scheduled to work on "Wednesday" from "0700-1500". 3. In an interview, E6 reported the staffing schedule is a "set schedule" and the schedule remains the same for each week in the month. 4. A review of E4's personnel file revealed a scanned photo of a CPR and first aid card. The card stated "CERTIFICATION CARD AMERICAN EMERGENCY RESPONSE TRAINING". The card contained a box which included a check mark for "CPR/AED/FIRST AID (adult/child/infant)" and included E4's name at the bottom. However, the card did not include a date of when the training was completed. 5. In an interview, E1 reported E1 believed the CPR and first aid training for E4 was current. E1 reported the card contained a date the training was completed on the back of the card, however, E1 could not locate documentation. 6. In an exit interview, the findings were reviewed with E1, and no additional statements or documentation were provided.

rule: R9-10-707.A.13.b. 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: b. As specified in R9-10-113.

evidence: Based on record review and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a potential TB exposure risk to residents.

findings: 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). A.A.C. R9-10-113(B)(1)(a)(i)(ii) 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 specific 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); i. Was administered within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution. 1. A review of R1's medical record revealed revealed no documentation of baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB. 2. In an interview, E1 reported R1 had completed baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and R1 provided evidence of freedom from infectious TB. However, E1 could not locate the documentation. 3. In an exit interview, the findings were reviewed with E1, and no additional statements or documentation were provided.

rule: R9-10-712.C.9. Medical Records C. An administrator shall ensure that a resident's medical record contains: 9. Orders;

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

findings: 1. A review of R1’s medical record revealed a daily medication administration record (MAR). The MAR revealed R1 was provided "Atorvastatin 20 mg 1 tab daily oral" on January 28, 2026 at "08:00". 2. A review of R1's medical record revealed medication orders dated October 15, 2025. However, the medication orders did not include "Atorvastatin 20 mg". 3. In an interview, E1 reported R1 sees a separate primary care physician "Atorvastatin 20 mg". E1 acknowledged the medication order for "Atorvastatin 20 mg" was not in R1’s medical record. 4. In an exit interview, the findings were reviewed with E1, and no additional statements or documents were provided.


summary: Complaint;Compliance (Annual) - 2/19/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 0097220 conducted on February 19, 2025.

rule: R9-10-706.B.3.b. 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: b. Meet the needs of a resident, and

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 and experience necessary to meet the needs of a resident. The deficient practice posed a risk as R1 self harmed at the facility.

findings: 1. A review of Department documentation revealed BH5290 was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently. 2. A review of R1's medical record revealed R1 had a guardian. 3. A review of facility documentation revealed an incident report, dated January 27, 2025. The incident report stated "January 25, 2025 at approximately 19:45, member [R1] was preparing for medication self administration. [R1] stated to staff 1 that [R1] wanted to use the restroom. [R1] spent approximately 15 minutes in the restroom before staff 1 asked [R1] if [R1] was ok and that it was time for medication administration and cigarette break time. [R1] then came out of the restroom and presented being positive and showed no signs of agitations/being upset. [R1] proceeded to step outside into the designated smoking area. While staff put away an item, [R1] showed [R1's] peer cuts (who was outside at the designated smoking area located on [R1's] left shoulder area. [R1's] peer stated to staff 1 and 2 to check [R1's] arm because [R1] cut [R1]...[R1] was asked if [R1] cut [R1] and where and [R1] was in denial. [R1] continued to be in denial until after approximately 10-15 attempts of having [R1] show staff the cuts. [R1] states that [R1] cut [R1] with a small light bulb. [R1] did not confiscate the light bulb to staff at this time after approximately 10 attempts. [R1] proceeded to go into [R1's] bedroom and at this time [R1] stated to staff that [R1] cut [R1] but [R1] did not want to report the incident nor did [R1] want to show the cuts. [R1] eventually showed [R1's] shoulder. [R1[ was asked again if [R1] could turn in the light bulb [R1] used and [R1] refused. [R1] was asked where [R1] grabbed the light bulb from and [R1] stated the office drawer...While [R1] was outside (at approximately 8:30), [R1] attempted to leave through the backyard gate and was unsuccessful. [R1] went back inside the home and into the master bedroom bathroom where [R1] closed [R1] in again. Staff 1 continued to get [R1] to step out of the bathroom. During this time, staff 1 advised staff 2 to contact the Crisis team. The Crisis team was contacted at approximately 20:40; Approximately 2 minutes after the crisis team was notified, [R1] stepped outside of the bathroom and turned on [sic] the light bulb...[R1] was monitored the entire time until the Crisis team...arrived at the facility. At approximately 23:00, the crisis team arrived at the home and spoke with staff 1, 2 and [R1]. [R1] stated to the crisis team that [R1] was not suicidal. The crisis team...asked [R1] if [R1] wanted to seek a higher level of care and [R1] stated yes. The crisis team contacted Valley hospital and asked if there was bed (s) available and the inpatient team..." 4. In a joint interview, E2 reported R1 was on a one on one with staff, and staff were always present with R1. E1 and E2 acknowledged R1 was able to obtain a lightbulb when staff were not looking, and later used the lightbulb to self harm. 5. In an exit interview, the findings were reviewed with E1 and E2, and no further statements or documentation were provided.

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 one 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 specific 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 E3's personnel record (hired in 2024) revealed E3's personnel record included an initial TST test. However, documentation of E3'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 2024) revealed E4's personnel record included an initial TST test. However, 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 E2, and no further statements or documentation was provided.

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

evidence: Based on documentation review, record review and interview, the administrator failed to ensure a resident admitted to the behavioral health residential facility with limited ability to function independently received continuous protective oversight. The deficient practice posed a risk as R1 was able to self harm.

findings: 1. A review of Department documentation revealed BH5290 was licensed to provide behavioral health services to individuals whose behavioral health issue limits the individuals' ability to function independently. 2. A review of R1's medical record revealed R1 had a guardian. 3. A review of facility documentation revealed an incident report, dated January 27, 2025. The incident report stated "January 25, 2025 at approximately 19:45, member [R1] was preparing for medication self administration. [R1] stated to staff 1 that [R1] wanted to use the restroom. [R1] spent approximately 15 minutes in the restroom before staff 1 asked [R1] if [R1] was ok and that it was time for medication administration and cigarette break time. [R1] then came out of the restroom and presented being positive and showed no signs of agitations/being upset. [R1] proceeded to step outside into the designated smoking area. While staff put away an item, [R1] showed [R1's] peer cuts (who was outside at the designated smoking area located on [R1's] left shoulder area. [R1's] peer stated to staff 1 and 2 to check [R1's] arm because [R1] cut [R1]...[R1] was asked if [R1] cut [R1] and where and [R1] was in denial. [R1] continued to be in denial until after approximately 10-15 attempts of having [R1] show staff the cuts. [R1] states that [R1] cut [R1] with a small light bulb. [R1] did not confiscate the light bulb to staff at this time after approximately 10 attempts. [R1] proceeded to go into [R1's] bedroom and at this time [R1] stated to staff that [R1] cut [R1] but [R1] did not want to report the incident nor did [R1] want to show the cuts. [R1] eventually showed [R1's] shoulder. [R1[ was asked again if [R1] could turn in the light bulb [R1] used and [R1] refused. [R1] was asked where [R1] grabbed the light bulb from and [R1] stated the office drawer...While [R1] was outside (at approximately 8:30), [R1] attempted to leave through the backyard gate and was unsuccessful. [R1] went back inside the home and into the master bedroom bathroom where [R1] closed [R1] in again. Staff 1 continued to get [R1] to step out of the bathroom. During this time, staff 1 advised staff 2 to contact the Crisis team. The Crisis team was contacted at approximately 20:40; Approximately 2 minutes after the crisis team was notified, [R1] stepped outside of the bathroom and turned on [sic] the light bulb...[R1] was monitored the entire time until the Crisis team...arrived at the facility. At approximately 23:00, the crisis team arrived at the home and spoke with staff 1, 2 and [R1]. [R1] stated to the crisis team that [R1] was not suicidal. The crisis team...asked [R1] if [R1] wanted to seek a higher level of care and [R1] stated yes. The crisis team contacted Valley hospital and asked if there was bed (s) available and the inpatient team..." 4. In a joint interview, E2 reported R1 was on a one on one with staff, and staff were always present with R1. E1 and E2 acknowledged R1 was able to obtain a lightbulb when staff were not looking, and later used the lightbulb to self harm. Additionally, E1 and E2 acknowledged R1 was unsupervised in the backyard area, while a staff member went to put an item away, as stated in the incident report. 5. In an exit interview, the findings were discussed with E1 and E2, and no additional statements or documentation were provided.

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

findings: R9-10-101.32. "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. 1. During an environmental tour of the facility, the Compliance Officer observed, in an unlocked kitchen drawer, one pizza cutter and one food grater with sharp edges. 2. A review of R1's (discharged 2025) medical record revealed a behavioral health assessment dated in 2024. The document stated "What is the risk? [R1] will attempt to cut [R1] and/or elope from the facility." 3. A review of facility documentation revealed an incident report, dated January 27, 2025. The incident report stated "January 25, 2025 at approximately 19:45, member [R1] was preparing for medication self administration. [R1] stated to staff 1 that [R1] wanted to use the restroom. [R1] spent approximately 15 minutes in the restroom before staff 1 asked [R1] if [R1] was ok and that it was time for medication administration and cigarette break time. [R1] then came out of the restroom and presented being positive and showed no signs of agitations/being upset. [R1] proceeded to step outside into the designated smoking area. While staff put away an item, [R1] showed [R1's] peer cuts (who was outside at the designated smoking area located on [R1's] left shoulder area. [R1's] peer stated to staff 1 and 2 to check [R1's] arm because [R1] cut [R1]...[R1] was asked if [R1] cut [R1] and where and [R1] was in denial. [R1] continued to be in denial until after approximately 10-15 attempts of having [R1] show staff the cuts. [R1] states that [R1] cut [R1] with a small light bulb. [R1] did not confiscate the light bulb to staff at this time after approximately 10 attempts. [R1] proceeded to go into [R1's] bedroom and at this time [R1] stated to staff that [R1] cut [R1] but [R1] did not want to report the incident nor did [R1] want to show the cuts. [R1] eventually showed [R1's] shoulder. [R1[ was asked again if [R1] could turn in the light bulb [R1] used and [R1] refused. [R1] was asked where [R1] grabbed the light bulb from and [R1] stated the office drawer...While [R1] was outside (at approximately 8:30), [R1] attempted to leave through the backyard gate and was unsuccessful. [R1] went back inside the home and into the master bedroom bathroom where [R1] closed [R1] in again. Staff 1 continued to get [R1] to step out of the bathroom. During this time, staff 1 advised staff 2 to contact the Crisis team. The Crisis team was contacted at approximately 20:40; Approximately 2 minutes after the crisis team was notified, [R1] stepped outside of the bathroom and turned on [sic] the light bulb...[R1] was monitored the entire time until the Crisis team...arrived at the facility. At approximately 23:00, the crisis team arrived at the home and spoke with staff 1, 2 and [R1]. [R1] stated to the crisis team that [R1] was not suicidal. The crisis team...asked [R1] if [R1] wanted to seek a higher level of care and [R1] stated yes. The crisis team contacted Valley hospital and asked if there was bed (s) available and the inpatient team..." 4. A review of R2's (a current resident) medical record revealed a nursing assessment dated in 2025. The document stated "...[R2] told RN [R2] cuts [R2] with whatever sharp object [R2] can find..." 5. A review of R2's medical record revealed a behavioral health assessment dated in 2025. The document stated "[R2] struggles a lot with anxiety which will lead to bad decision(s) such as physical aggression, sexual comments/statements, threatening other(s) and suicidal ideation..." 6. In a joint interview, E2 reported R1 was on a one on one with staff, and staff were always present with R1. E1 and E2 acknowledged R1 was able to obtain a lightbulb when staff were not looking, and later used the lightbulb to self harm. 7. In an exit interview, the findings were reviewed with E1 and E2 and no further statements were made.

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, documentation review, and interview, the administrator failed to ensure assistance in the self-administration of medication was provided to a resident in compliance with an order. The deficient practice posed a risk if R2 experienced a change in condition due to not taking the prescribed medication.

findings: 1. A review of R2's medical record revealed a medication order, dated February 11, 2025. The order stated stated "Rexulti 0.25 mg take 1 tablet by mouth every night." 2. A review of R2's medical record revealed a medication administration record (MAR) dated February 2025. The MAR revealed assistance in the self-administration of medication for "Rexulti 0.25 mg" was provided on February 18, 2025. However, documentation indicating R2 was provided "Rexulti 0.25 mg" beginning on February 11, 2025, in compliance with R2's medication order, was not available for review. 3. In an interview, E2 reported the medical practitioner did not submit the order to the pharmacy until February 18, 2025, and R2 received the medication on February 18, 2025. 4. In an exit interview, the findings were reviewed with E1 and E2, and no further statements or documentation was provided.

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 which may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk, as a ligature point was identified.

findings: 1. During an environmental tour of the facility, the Compliance Officer observed one grab bar, mounted to a wall in a hallway bathroom. 2. In an interview, E1 and E2 acknowledged the grab bar in the hallway bathroom was a ligature point. 3. In an exit interview, the findings were discussed with E1 and E2 and no further statements were provided.


summary: Compliance (Initial) - 6/11/2024

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on June11, 2024.

inspection_type: Compliance (Initial)


summary: Compliance (Annual) - 5/19/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on May 19, 2023:

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

evidence: Based on documentation review, record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records 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 "Section 22. Training." The policy stated "Fall Prevention is a training to help prevent an unexpected fall. It is a defensive tool to help our members as best as we can to prevent he/she from falling. Fall prevention is complete for every new hire at new hire training. This will be completed annually thereafter or as needed. Education can be found on the website at https://ncoa.org/older-adults/health/prevention/falls-prevention". 2. A review of E2's and E3's personnel records revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 3. In a interview, E1 reported staff are trained by reading through the aforementioned website, and a form is kept in their personnel records to indicate completed fall prevention and fall recovery training. E1 acknowledged there was no documentation in E2's and E3's personnel records to indicate the facility administered a training program for all staff regarding fall prevention and fall recovery. This is a repeat citation from the previous on-site compliance inspection conducted on May 23, 2022.

evidence: Based on 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.

findings: 1. A review of the facility's policies and procedures revealed a policy titled "Behavioral Health Professional." The policy stated: "General: The Behavioral Health Professional (BHP) shall provide Clinical Oversight at Golden Heart Care in accordance with the following: Duties and Responsibilities: The BHP collaborates with the agency Administrator to provide clinical oversight to staff (BHPP's and BHT's). Monitors the behavioral health services provided by a behavioral health technician (BHT) and/or a behavioral health paraprofessional (BHPP) to ensure that the BHT or BHPP provides services in accordance with agency policies and procedures. (Note: An RN, employed as a BHT may be supervised by the BHP provided the RN performs no nursing responsibilities for the agency and is not employed by the agency in a nursing capacity.) Provides on-going review of a BHT and BHPP skills and knowledge related to their ability to provide behavioral health services to group home clients. Provides guidance to improve a BHT's or BHPP's job skills and knowledge." However, the policy did not include the required skills and knowledge for a BHP. 2. A review of E2's personnel record revealed E2 was hired as a BHP. However, documentation to demonstrate E2's skills and knowledge were verified and documented was not available for review. 3. A review of E2's personnel record revealed E2 was hired as a BHP. However, documentation of E2's completed orientation was not available for review. 4. A review of R1's medical record revealed individual counseling session notes dated May 11, 2023 and May 18, 2023. However, documentation to demonstrate R1 received individual counseling two times weekly for 30 minute sessions prior to May 11, 2023, as indicated in R1's treatment plan, was not available for review. 5. A review of R2's medical record revealed individual counseling session notes for May 11, 2023 and May 16, 2023. However, documentation to demonstrate R2 received individual counseling two times weekly for 30 minute sessions prior to May 11, 2023, as indicated in R2's treatment plan, was not available for review. 6. A review of E2's and E3's personnel records revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 7. In an interview, E1 acknowledged documentation required by this Article was not provided to the Department within two hours after a Department request.

rule: B. An administrator shall ensure that: 2. A personnel member's skills and knowledge are verified and documented: a. Before the personnel member provides physical health services or behavioral health services, and b. According to policies and procedures; and

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member's skills and knowledge was verified and documented before the personnel member provided behavioral health services, and according to policies and procedures, for one of three personnel members sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the documentation was not in the personnel records 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 a policy titled "Behavioral Health Professional." The policy stated: "General: The Behavioral Health Professional (BHP) shall provide Clinical Oversight at Golden Heart Care in accordance with the following: Duties and Responsibilities: The BHP collaborates with the agency Administrator to provide clinical oversight to staff (BHPP'S and BHT'S). Monitors the behavioral health services provided by a behavioral health technician (BHT) and/or a behavioral health paraprofessional (BHPP) to ensure that the BHT or BHPP provides services in accordance with agency policies and procedures. (Note: An RN, employed as a BHT may be supervised by the BHP provided the RN performs no nursing responsibilities for the agency and is not employed by the agency in a nursing capacity.) Provides on-going review of a BHT and BHPP skills and knowledge related to their ability to provide behavioral health services to group home clients. Provides guidance to improve a BHT's or BHPP's job skills and knowledge." However, the policy did not include the required skills and knowledge for a BHP. 2. A review of E2's personnel record revealed E2 was hired as a BHP. However, documentation to demonstrate E2's skills and knowledge were verified and documented was not available for review. 3. In an interview, E1 acknowledged E2's skills and knowledge were not verified and documented before E2 provided behavioral health services and according to policies and procedures.

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member completed orientation before providing behavioral health services, for one of three personnel members sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

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 the facility's policies and procedures revealed an undated policy titled "Section 22. Training Required Training." The policy stated: "All Golden Heart Care employees participate in an extensive New Employee Orientation that meets the requirements of our funding sources. Some of these include: Incident Report Writing, Clinical Progress Notes documentation, Medication Administration Training, First Aid/CPR, ABC Analysis training, clinical book documentation training, fall prevention training and more. These classes occur in a classroom setting. New Employee Orientation provides detailed information about the type of work and services the company performs; the expectation of excellence in services provided; the techniques, knowledge and skills used in delivering services; and the rules, regulations, and procedures governing the services the company provides. All employees are required to complete the New Employee Orientation before working a regular shift. Continued employment with Golden Heart Care relies on the successful completion of New Employee Orientation...All orientation paperwork will be scanned into Yellowstone in the employees file." 3. A review of E2's personnel record revealed E2 was hired as a Behavioral Health Professional (BHP). However, documentation of E2's completed orientation was not available for review. 4. In an interview, E1 acknowledged E2's orientation was not completed prior to E2 providing behavioral health services.

rule: 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.

findings: 1. During the environmental inspection of the facility, the Compliance Officer did not observe the requirements in subsection (B) and the resident rights in subsection (E) conspicuously posted on the premises. 2. In an interview, E1 acknowledged the requirements and the rights from subsections (B) and (E) were not conspicuously posted on the premises.

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 two of two residents sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

findings: 1. A review of R1's medical record revealed a treatment plan dated April 25, 2023. The treatment plan stated "Objective(s): [R1] will complete counseling 2 times weekly for 30 minute sessions." 2. A review of R1's medical record revealed individual counseling session notes for May 11, 2023 and May 18, 2023. However, documentation to demonstrate R1 received individual counseling two times weekly for 30 minute sessions prior to May 11, 2023, as indicated in R1's treatment plan, was not available for review. 3. A review of R2's medical record revealed a treatment plan dated April 25, 2023. The treatment plan stated "Objective(s): [R2] will complete counseling two times weekly (30-minute sessions each)." 4. A review of R2's medical record revealed individual counseling sessions notes for May 11, 2023 and May 16, 2023. However, documentation to demonstrate R2 received individual counseling two times weekly for 30 minute sessions prior to May 11, 2023, as indicated in R2's treatment plan, was not available for review. 5. In an interview, E1 acknowledged counseling was not provided according to the frequency in R1's and R2's treatment plans. This is a repeat citation from the previous on-site compliance inspection conducted on May 23, 2022.


facility_name: NEW HOPE OF ARIZONA, INC

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

raw_content: No deficiencies were found during the on-site compliance inspection conducted on June 6, 2025.


summary: Compliance (Annual) - 6/27/2024

raw_content: No deficiencies were found during the on-site compliance inspection conducted on June 27, 2024. Based on this deficiency-free compliance inspection, the Department shall not conduct a compliance inspection for twenty-four months, according to A.R.S. \'a7 36-425(E). Subsection (E) does not prohibit the Department from enforcing licensing requirements as authorized by A.R.S. \'a7 36-424.


summary: Compliance (Annual) - 6/26/2023

raw_content: The following deficiencies were found during the on-site compliance inspection conducted on June 26, 2023:

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

evidence: Based on documentation review, record review, and interview, the administrator failed to ensure behavioral health services listed in the behavioral health residential facility's scope of services were provided on the premises.

findings: 1. A review of the facility policies and procedures reviewed July 1, 2020, revealed a scope of services. The scope of services stated, "...Behavioral Health Residential Services provides a structured treatment setting with twenty four hour supervision and counseling..." 2. A review of R1 and R2's treatment plans revealed no documentation of counseling identified in the residents medical record. 3. In an interview, E1 reported the identified facility residents receive respite services. E1 acknowledged the facility is licensed as a behavioral health residential facility. E1 acknowledged the behavioral health services listed in the behavioral health residential facility's scope of services were not provided on the premises.


facility_name: DALIA HOMECARE LLC

summary: Complaint;Compliance (Annual) - 10/21/2025

raw_content: The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00138287 conducted on October 21, 2025:

rule: R9-10-707.A.6. Admission; Assessment A. An administrator shall ensure that: 6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission;

evidence: Based on record review and interview, the administrator failed to ensure a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission. The deficient practice posed a health risk as the resident could have had medical complications without notifying the staff.

findings: 1. A review of R1's medical record revealed a nursing assessment that was completed on July 8, 2025, five calendar days after the resident's admission to the facility. 2. In an interview, E1 reported nursing assessments are to be completed within 30 days after admission. 3. In an exit interview, the findings were reviewed with E1. No additional comments or documents were provided.