Ahwatukee Comfort Care, LLC

Based on documentation review and interview, the manager failed to ensure that policies and procedures were established, documented, and implemented to protect the health and safety of a resident. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Review of the facility's Policies and Procedures revealed no policy for the general or specific whereabouts of a resident. 2. In an interview, E2 acknowledged that that policies and procedures were not established, documented, and implemented.

Based on documentation review, observation, and interview, the manager failed to ensure there was 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 which provided access to an outside area which monitored or alerted employees of the egress of a resident from the facility. Findings include: 1. Review of Department documentation revealed the facility was licensed for directed level of care. 2. The Compliance Officer observed a door in R2’s room, leading to the backyard, which did not have any monitoring or alerts to alert employees of the egress of a resident from the facility. 3. In an interview, E2 acknowledged there was 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 which provided access to an outside area which did not monitor or alert employees of the egress of a resident from the facility.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the following in an unlocked refrigerator: -Trulicity 1.5 MG/0.5 ML; -Lorazepam con 2 mg/mL 0.25ML (0.5MG) per syringe quantity 5; -Morphine 20 mg/ml 0.25ML (0.5MG) per syringe quantity 20; -Lantus Solostar Pen INJ 3ML 10 unit; -Ondansetron TAB 4MG ODT. 2. In an interview, E2 acknowledged medication was unlocked and accessible to residents.

Based on observation and interview, the manager failed to ensure that toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed one bag of "Finish Powerball dishwasher tabs" and a bottle of "Ajax" in an unlocked kitchen cabinet. The cabinet did have a locking device however, it was not working at the time. 2. In an interview, E2 acknowledged that the poisonous or toxic materials were accessible to residents and stored unlocked.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. Findings include: Arizona Revised Statutes (A.R.S.) \'a7 36-420.01. states: "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." 1. A review of facility policies and procedures revealed no documentation to indicate a fall prevention and fall recovery training program was developed. 2. A review of E1's and E2's personnel records revealed documentation of initial training conducted on November 18, 2021, through a third party training program. However evidence of continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 confirmed E1 and E2 completed a training course in fall prevention in November of 2021. E1 reported the facility was not aware employee's needed to complete annual continued competency training.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's (accepted in 2023) medical record revealed documentation to include whether R1 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant. However, the document was signed by a medical practitioner 13 days after R1 was accepted by the assisted living facility. 2. In an interview, E1 acknowledged R1 did not submit documentation dated 90 calendar days before the individual was accepted by the assisted living facility.

Based on documentation review, record review, and interview, the manager accepted and retained an individual who required continuous behavioral health services, for one of ten residents sampled. The deficient practice posed a risk as the health care institution was not authorized to provide behavioral health services. Findings include: Arizona Revised Statutes (A.R.S.) \'a7 36-401.11. "Behavioral health services" means "services that pertain to mental health and substance use disorders and that are either: (a) Performed by or under the supervision of a professional who is licensed pursuant to title 32 and whose scope of practice allows for the provision of these services. (b) Performed on behalf of patients by behavioral health staff as prescribed by rule." A.R.S. \'a7 36-401.13. "Continuous" means "available at all times without cessation, break or interruption." 1. A review of Department documentation revealed the facility was not authorized to provide behavioral health services. 2. A review of the facility's scope of services revealed the scope of services did not include behavioral health services as an identified service to be provided to residents. 3. A review of R1's medical record revealed a document titled, "Determination For Admission," signed and dated by a medical practitioner on October 4, 2022, which stated, "Does this person require continuous behavioral health services? (i.e. under the direction of a behavioral health professional)." The medical practitioner signed the document and marked "yes" for the aforementioned question. 4. In an interview, E1 reported the documentation may have been filled out incorrectly by R2's medical practitioner. E1 reported E1 would have the determination corrected by requesting the medical practitioner on staff re-evaluate R2 to be sure the facility was still appropriate for R2's level of care.