Amazing Comfort Homes LLC

Based on record review, documentation review, and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, and according to policies and procedures for two of the two employees sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. A review of E1's personnel record revealed no documentation of skills and knowledge verification present in their record. Based on E1's hire date, this information was required. 2. A review of E2's personnel record revealed no documentation of skills and knowledge verification present in their record. Based on E2's hire date, this information was required. 3. A review of the facility's staff schedule revealed E1 and E2 worked complete shifts during the month of January 2026. 4. A review of the facility's policies and procedures revealed a section titled, "Caregiver and Relievers Duties and Responsibilities" with the following verbiage, "A Caregiver or Reliever will complete a skills questionnaire to ensure that they have experience, knowledge and skills to complete the requirements of the job." 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on interview and record review, the manager failed to ensure that the written notice of termination of residency included the policy for refunding fees, charges, or deposits, the deposition of a resident’s fees, charges, and deposits, and contact information for the State Long-Term Care Ombudsman. Findings include: 1. In an interview, E1 reported that R1’s residency at the facility was terminated on January 2, 2026. E1 reported that the termination was initiated by the facility. 2. A review of R1's medical record revealed no documentation of a written notice of termination that included the policy for refunding fees, charges, or deposits, the deposition of a resident’s fees, charges, and deposits, and the contact information for the State Long-Term Care Ombudsman. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented according to policies and procedures, for two of four personnel members sampled. The deficient practice posed a risk if an employee did not have the skills and knowledge to ensure the health and safety of residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Staffing, Hiring and Discipline." The policy stated "Verification of qualification, knowledge, and skills to perform the duties of the job hired for." 2. Review of E2's and E5's personnel records revealed no documentation to indicate E2's and E5's skills and knowledge were verified. 3. In an interview, E1 acknowledged documentation indicating E2's and E5's skills and knowledge were verified and documented was not available for review at the time of the inspection.

Based on documentation review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. Findings include: 1. A review of facility documentation revealed an incident report dated January 14, 2024, for R1. The incident report did not give a description of the incident. However, the incident report revealed E3 held a meeting with E5 and told E5 "not to do it again." 2. In an interview, E1 reported on January 14, 2024, E5 and R1 had gotten into an argument about medication. R1 had complained about E5 not giving R1 medication to have by R1's bed side. A few days after this incident E1 reported E5 had called R1 an explicit name due to R1 complaining about E5. E1 reported when the facility found out about the incident, E1 reported it to Adult Protective Services, and E5's employment was terminated.

Based on documentation review, record review, and interview, the manager failed to ensure a resident was not subjected to seclusion. The deficient practice posed a risk if a resident or other individual could be locked in a bedroom. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(205) states "[s]eclusion" means "the involuntary solitary confinement of a patient in a room or an area where the patient is prevented from leaving." 2. A review of R1's medical record revealed a service plan dated December 12, 2023. The service plan revealed R3 received directed care services. 3. A review of facility documentation revealed an incident report dated January 22, 2024. The incident report revealed R3 was trying to get out of R3's bedroom and E5 had locked the door. In the section titled "action taken by the home at the time of the incident" the incident report stated E3 let E5 know staff could not lock the door. Under "action taken by the home to prevent reoccurrence" the incident report stated E3 told E5 not to do it again. 4. In an interview, E1 confirmed R3 was locked in R3's bedroom alone for several hours by E5. 5. In a separate interview, E5 admitted to locking R3 in R3's bedroom for several hours.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a health and safety risk to residents with access to the medications. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet in the kitchen area. The cabinet contained bottles of "Aspirin" and "Atorvastatin" medications. 2. In an interview, E1 acknowledged the aforementioned medications were not stored in a locked area and were accessible to residents.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95\'b0 F and 120\'b0 F in areas of the assisted living facility used by residents. The deficient practice posed a potential burn risk to residents. Findings include: 1. Using a Department-issued thermometer, the Compliance Officer observed the hot water temperature measured 130.2\'b0 F in a shared resident bathroom. 2. In an interview, E1 acknowledged the hot water temperature was not maintained between 95\'b0 F and 120\'b0 F in the shared resident bathroom. E1 reported the facility recently had work done and the hot water heater was reset. E1 adjusted the temperature setting on the facility water heater during the inspection.