AT HOME CHOLLA

INSP-0134785

Complete

Date: 6/26/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-07-22

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on June 26, 2025:

Deficiencies Found: 5

Deficiency #1

Rule/Regulation Violated:

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/Findings:

Based on the documentation review, record review, and interview, the health care institution failed to administer a training program for three of the three staff sampled regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety were not implemented. Findings include:1. A review of the facility's policies and procedures revealed a policy titled "Fall Prevention and Recovery" that stated "Fall Prevention and Recovery Training is required upon hire and at least every 12 months thereafter". 2. A review of E1's personnel record revealed a hire date of September 2020. E1's record revealed fall prevention and fall recovery for 2020, 2022, and 2025. However, the record did not contain documentation of fall prevention and fall recovery training for 2021, 2023, and 2024. 3. A review of E2's personnel record revealed a hire date of June 2022. E2's record revealed fall prevention and fall recovery for 2023 and 2025. However, the record did not contain documentation of fall prevention and fall recovery training for 2022 and 2024. 4. A review of E3's personnel record revealed a hire date of June 2020. E3's record revealed fall prevention and fall recovery for 2023 and 2025. However, the record did not contain documentation of fall prevention and fall recovery training for 2022 and 2024. 5. In an interview, E4 acknowledged that the facility failed to administer a fall prevention and fall recovery training for all staff upon hire and at least every 12 months thereafter.

Temporary Solution:

An audit of resident records was conducted and request of records to the staff happened.

Permanent Solution:

Management will make sure ALL yearly TRAINING will be monitored through an audit tool.
Please see attachment.

Person Responsible:

Mariela Flores

Deficiency #2

Rule/Regulation Violated:

R9-10-808.C.1.c. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: c. Provides assistance with activities of daily living according to the resident's service plan;

Evidence/Findings:

Based on the record review and interview, the manager failed to ensure that a caregiver or assistant caregiver provided assistance with activities of daily living according to the resident's service plan for two of the two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated April 1, 2025. R1's service plan indicated R1 required assistance with:- combing hair daily, - foot care, and;- Incontinence check every 2 hours and PRN. 2. A review of R1’s activities of daily living (ADL) document revealed that 'combing hair daily' and foot care were not listed in R1's ADL. Also, the service plan revealed that incontinence checks were not provided every two hours as needed, as specified in the R1’s service plan. 3. A review of R2's medical record revealed a service plan dated June 1, 2025. R2's service plan indicated R2 required assistance with:- combing hair daily, and;- Incontinence check every 2 hours and PRN. 4. A review of R2’s activities of daily living (ADL) document revealed that 'combing hair was not listed in R2's ADL. Also, the ADL revealed that incontinence checks were not provided every two hours or as needed, as specified in the R2’s service plan. 5. In an interview, E4 acknowledged that R1's and R2’s documentation of services provided did not reflect what was on the service plan.

Temporary Solution:

Manager made corrections in ADP and Service Plan forms as mandated by DHS inspector

Permanent Solution:

The ADL sheet for July includes additional information regarding DAILY HAIR COMBING following the resident Service Plan directive.
The Service Plan tool includes the FOOT CARE Service provided by PODIATRIST as shows in the attachment.

Person Responsible:

Mariela Flores/ Manager Designee

Deficiency #3

Rule/Regulation Violated:

R9-10-816.D.1. Medication Services D. A manager shall ensure that: 1. A current drug reference guide is available for use by personnel members, and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure there was a current drug reference guide that was available for use by personnel members. This posed a health and safety risk to the resident if the caregiver was unable to reference a medication a resident was taking. Findings include: 1. During the environmental tour, the Compliance Officer observed that the facility was providing medication administration services. 2. The Compliance Officer requested the current drug reference guide. However, the drug reference guide was not provided to the department for review. 3. In an interview, E4 acknowledged that the facility did not have a drug reference guide available for use by personnel members

Temporary Solution:

Drugs.com application was downloaded to all employees on their mobile devices during DHS inspection event

Permanent Solution:

Manager ensures all staff have the DRUGS.com application downloaded to their mobile devices and should be used as a reference anytime there is a inquiry regarding medication or pills.

Person Responsible:

Mariela Flores / Manager Designee

Deficiency #4

Rule/Regulation Violated:

R9-10-819.A.1.a. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: a. Cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection; and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that the premises and equipment were cleaned and disinfected. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed an outside seating area with a buildup of dirt and bird feces on the table and chairs 2. In an interview, E4 acknowledged that the premises were not cleaned or disinfected.

Temporary Solution:

Employee cleaned the backyard TABLE

Permanent Solution:

Management had include the backyard area and table to be cleaned and sanitized weekly. Please see Cleaning Schedule attached to this correction.

Person Responsible:

Mariela Flores / Manager Designee

Deficiency #5

Rule/Regulation Violated:

R9-10-818.C.4.a. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 4. Potentially hazardous food is maintained as follows: a. Foods requiring refrigeration are maintained at 41° F or below; and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that foods requiring refrigeration were maintained at 41°F or below. The deficient practice posed a health risk to the residents. Findings include: 1. The Compliance Officer observed a refrigerator in the kitchen that contained food items. However, the thermometer in the refrigerator indicated a temperature of 55°F. 2. In an interview, E4 acknowledged that foods requiring refrigeration were not maintained at 41°F or below.

Temporary Solution:

The refrigerator temperature was manually set to 36 degrees to resolve the issue

Permanent Solution:

Manager Designee set the refrigerator temperature to 36 degrees during DHS inspection

Person Responsible:

Mariela Flores / Manager Designee

INSP-0061957

Complete

Date: 5/6/2024

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2024-06-10

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on May 6, 2024: On September 10, 2024 an off-site review of the plan of correction was conducted. The plan of correction was accepted for all citations.

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

F. When medication is stored by an assisted living facility, a manager shall ensure that:
1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practiced posed a potential risk to the health and safety of residents.

Findings include:

1. The Compliance Officer observed R2's mediset was stored in a cabinet that was not secure and was accessible to residents.

3. In an interview, E1 reported that R2's mediset was stored in a cabinet that was not secure and was accessible to residents.

Deficiency #2

Rule/Regulation Violated:

A. A manager shall ensure that:
4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

Evidence/Findings:

Based upon record review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees.

Findings include:

1. A review of a record titled "Disaster Drill" revealed that a disaster drill was conducted on March 1, 2024 from 11:10am to 11:30am. There was not a second shift disaster drill conducted.

2. A review of a record titled "Disaster Drill" revealed that a disaster drill was conducted on December 1, 2024 from 10:00am to 10:15am. There was not a second shift disaster drill conducted.

3. In an interview, E1 acknowledged that there was not a second shift disaster drill conducted on the above days and that there was no further evidence of a second shift disaster drill being conducted.

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
1. The premises and equipment used at the assisted living facility are:
b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

Evidence/Findings:

Based upon observation and interview, the manager failed to ensure that the premises of the facility was free from a condition or situation that may have caused a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers to the residents.

Findings include:

1. The Compliance Officer observed a path on the outdoor, east side of the facility that was blocked by debris and garbage. The blocked path did not allow for safe exit on the east side of the facility moving northbound.

2. In an interview, E1 acknowledged that there was debris and garbage along the outdoor, east side of the facility that did not allow for safe exit.

Deficiency #4

Rule/Regulation Violated:

A. A manager shall ensure that:
10. Oxygen containers are secured in an upright position;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that three of three oxygen containers were secured. The deficient practice posed a potential explosion or leak of a compressed gas.

Findings include:

1. The Compliance Officer observed three unsecured oxygen tanks in a closet at the facility.

2. In an interview, E1 confirmed that there were three unsecured oxygen tanks in a closet.

Facility Information

Inspection History

INSP-0134785

Summary:

Deficiencies Found: 5

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:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0061957

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings: