APOLLO RESIDENTIAL ASSISTED LIVING

INSP-0130022

Complete

Date: 4/24/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-05-15

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on April 24, 2025.

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

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, occupation 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/Findings:

Based on record review and interview, the health care institution’s chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed to the health care institution, for two of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1's, E2's, and E3's personnel record did not include documentation of initial and annual training on recognizing the signs and symptoms of TB. 2. In an interview, E1 acknowledged that E1's, E2’s, and E3’s records did not contain the training and education related to recognizing the signs and symptoms of tuberculosis (TB). E1 reported that he was not aware of the annual staff training for signs and symptoms of TB.

Temporary Solution:

All current staff, including E1, E2, and E3, have completed the CDC’s Tuberculosis (TB) training module online as an immediate corrective action. Certificates of completion are now filed in their personnel records. A training verification checklist has also been implemented to ensure proper documentation. Staff have been reminded that annual TB education is mandatory and must be completed and recorded. This action addresses the immediate concern and ensures staff are informed of the signs and symptoms of tuberculosis.

Permanent Solution:

We have updated our orientation and annual training program to include TB education using CDC guidelines. TB training will now be part of the new hire onboarding and repeated annually during mandatory in-service education. Training materials will cover TB transmission, symptoms, prevention, and reporting requirements per the CDC guidelines. A designated staff member will coordinate TB education to ensure full regulatory compliance under R9-10-113.A.2.c.

Person Responsible:

Dr. Christopher Zambakari, Owner and Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-818.A.2. Emergency and Safety Standards A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure that the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. A review of facility documentation revealed that the Disaster Plan was last reviewed in 2023. 2. In an interview, E1 acknowledged that the Disaster plan was not reviewed at least once every 12 months.

Temporary Solution:

As a temporary corrective action, the facility manager immediately reviewed and located correct Disaster Plan on April 28, 2025, ensuring compliance with R9-10-818.A.2. The currently updated Policies and Procedure Manual had fallen behind the metallic drawer. Additionally, all staff have completed the CDC TB Training, confirming alignment with emergency preparedness and infection control practices. A staff-wide in-service meeting was conducted to ensure familiarity with the disaster plan and where it is located at the facility.

Permanent Solution:

To ensure long-term compliance, the Manager will review and conduct every December to ensure compliance with AZ DHS guidelines and align with our policy update cycle. The manager or designee will document the review date, revisions, and staff training. All new hires will be oriented on the current plan during onboarding. A standing calendar reminder and policy binder update log will serve as an internal compliance mechanism, ensuring the plan is never outdated or overlooked.

Person Responsible:

Dr. Christopher Zambakari, Owner and Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-819.A.11. Environmental Standards A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living 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/Findings:

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living 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. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed a cabinet under the kitchen sink that contained poisonous and toxic materials. The lock on the cabinet did not prevent a resident from opening the cabinet which contained the following items:<ul><li>Cascade dish soap</li><li>Can of Comet Bleach</li></ul> 2. In an interview, E1 acknowledged that poisonous or toxic materials were not stored in an area that was locked and inaccessible to residents.

Temporary Solution:

Upon identification, the facility immediately removed all toxic and poisonous materials from the unlocked kitchen cabinet and relocated them to a secured, staff-only utility closet. This was done while the Surveyors were onsite. A new lock was installed under the sink that is resident-accessible. Staff were retrained on proper chemical storage protocols, and signed documentation of understanding was placed in personnel files.

Permanent Solution:

The facility has implemented a written policy and retrained ALL Staff requiring that all poisonous or toxic materials be stored in clearly labeled containers, inside locked cabinets located away from resident-accessible areas and separate from food, dining, and medication storage. This policy is now part of new hire orientation and annual staff training. The under-sink area is now permanently restricted for cleaning product storage. Staff are reminded of this requirement through posted signage and quarterly safety refreshers.

Person Responsible:

Dr. Christopher Zambakari, Owner and Manager

INSP-0058023

Complete

Date: 10/5/2023

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2023-10-12

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on October 5, 2023:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

E. A manager shall ensure that:
1. A bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies is available in a bedroom being used by a resident receiving directed care services; or

Evidence/Findings:

Based on documentation review, observation and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom. The deficient practice posed a risk if residents were unable to summon help from personnel members

Findings include:

1. A review of Department documentation revealed the facility was authorized to provide directed care services.

2. The Compliance Officer observed no bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies in three resident bedrooms.

3. In an interview, E2 reported no bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in several resident's bedroom due to the residents having dementia.

4. In an interview, E1 acknowledged E1 failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom.

Deficiency #2

Rule/Regulation Violated:

A. A manager shall ensure that:
2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees.

Findings include:

1. A review of facility documentation revealed a disaster plan review conducted on August 10, 2020, and June 19, 2021. However, documentation of a disaster plan reviews in 2022 and 2023 were not available for review.

2. In an interview, E1 acknowledged E1 failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months.

APOLLO RESIDENTIAL ASSISTED LIVING

Facility Information

Inspection History

INSP-0130022

Summary:

Deficiencies Found: 3

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0058023

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings: