ALTA VISTA

INSP-0102028

Complete

Date: 3/21/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2025-04-07

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaints AZ00105709 and AZ00122422 conducted on March 21, 2025:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

R9-10-815.F.2.a-c. Directed Care Services F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; b. Provides access to an outside area: i. From which a resident may exit to a location at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; or c. Uses a mechanism that meets the Special Egress-Control Devices provisions in the International Building Code incorporated by reference in R9-10-104.01; and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure there is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that controls or alerts employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed two sliding glass doors leading to an outside area from a memory care unit. Both sliding glass doors had an alert. However, both alerts on both doors were turned off. 2 . In an interview, E1 acknowledged the door alerts were turned off in the memory care unit.

Temporary Solution:

Turned the alarms on and informed all caregivers with written notice in med-room that alarms are not to be turned off for any reason.
Scheduled an all-caregiver staff meeting for March 24th to review new procedures on alarms.

Permanent Solution:

Executive Director and Resident Services Manager updated the memory care daily task list to include checking that the doors alarms are working properly at the start of each shift.
Added monthly alarm battery check to executive director's schedule.

Person Responsible:

Danielle Hughart, Executive Director

Deficiency #2

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 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 an environmental inspection of the facility, the Compliance Officers observed an unlocked "Laundry Room" on the fourth floor of the facility. Inside the "Laundry Room" was a box of "Tide" Ulta Oxi laundry detergent, and a container and bag of "All" Mighty Pacs detergent pods. 2 . In an interview, E1 reported all laundry services are handled by staff members. E1 acknowledged poisonous or toxic materials stored by the assisted living facility were accessible to residents.

Temporary Solution:

Caregiver removed all poisonous/toxic materials from the laundry room and placed them in a locked area.

Permanent Solution:

Executive Director and Maintenance Director installed automatic locks to all laundry room doors. Only team members are able to unlock the doors.

Person Responsible:

Danielle Hughart Executive Director

No deficiencies were found during the on-site compliance inspection conducted on September 12, 2023. 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.

Facility Information

Inspection History

INSP-0102028

Summary:

Deficiencies Found: 2

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:

INSP-0058196

Summary: