At Home Cholla.

“Based on interview and documentation review, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder (EMS). The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident.   Findings include:   1. In an interview, E5 reported that the facility personnel contacted EMS on behalf of R3 on February 28, 2026. 2. A review of facility documentation revealed an incident report dated February 28, 2026, which revealed that the facility personnel contacted EMS on behalf of R3.   3. A review of facility documentation revealed a resident transfer check list document, which indicated facility personnel contacted EMS on behalf of R3 on February 28, 2026. However, the document did not include the following: - Whether R3 received medication services and a list of all R3’s prescription and over-the-counter medications, their dosages, and how frequently they are to be administered; - The address of R3's current pharmacy; - A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive; - The name and contact information for R3’s primary care physician and power of attorney or authorized representative; - Basic information about R3’s physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known; - The point-of-contact information for the assisted living home, including the telephone number, if available, cell phone number, and email address; and - A copy of R3’s health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living home to plan for R3’s discharge.   4. In an exit interview, the findings were reviewed with E5, and no additional information was provided.”

“Based on documentation review, record review, and interview, the health care institution failed to initiate cardiopulmonary resuscitation (CPR) in accordance with its certification training for CPR before the arrival of emergency medical services, to a resident who was nonresponsive or had a cessation of normal respiration, in accordance with that resident's advance directives, for one of three residents sampled. The deficient practice posed a risk to the physical health and safety of a resident.     Findings include:     1. A review of Department documentation dated February 28, 2026 revealed a sworn testimony which stated, “upon E27's arrival on scene, staff stated [R3] isn’t breathing and staff not performing any resuscitation efforts. Staff unable to recognize [R3] cardiac arrest/unresponsiveness. Staff did not perform any CPR. Staff unable to provide any face sheet with medical records, medications, or DNR. E27 had to obtain [R3] information on our own due to the facility staff's ineptness. [R3] DNR (invalid) was a copy with no signatures whatsoever.” 2. A review of facility documentation dated February 28, 2026 revealed the facility personnel contacted EMS on behalf of R3.   3. A review of R3’s medical record revealed a DNR. The DNR was incomplete, missing a physician's signature and a witness's signature for R3's directive. 4. In an interview, E5 reported that the staff did not perform CPR, since R3 had a DNR and the staff was aware of it. 5. In an interview, findings were reviewed with E5, and no additional information was provided.”

“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.”

“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.”

“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”

“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.”

“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.”

“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.”

“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.”

“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.”

“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.”