Arizona Comfort Care

Based on documentation review, record review, and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide to the emergency responders a written document that included all information required in A.R.S. § 36-420.04, for one of two applicable residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of facility documentation revealed an incident report dated January 6, 2026. The report revealed R1 had been transported to the hospital. 2. In an interview, when the Compliance Officer requested a copy of the documentation given to EMS in compliance with this statute, E1 reported "resident face sheet and MAR was provided". When the Compliance Officer asked if E1 had a copy of the documentation given to EMS, E1 stated, “No.” When the Compliance Officer asked if facility personnel gave EMS a document in compliance with this statute, E1 stated, “No, I was not aware of this new rule." 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that 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 an assisted living facility, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse. Findings include: 1. Record review revealed R1's pre-admission determination, which included whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner. However, this was not completed within 90 days before R1 was admitted to the facility. 2. In an exit interview, findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill included the identification of residents needing assistance for evacuation. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. Review of the evacuation drills revealed a drill conducted on October 26, 2025. However, the drill did not include the identification of residents needing assistance for evacuation. 2. In an interview, E1 reported that R1 and R2 were unable to ambulate with assistance and would need assistance during an evacuation. E1 acknowledged that the evacuation drill did not include the identification of residents needing assistance.

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. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of facility documents revealed a policy and procedure titled "Staff Training Program and Procedure (Fall Prevention and Recovery)" that stated "All new employees will undergo an Orientation and review with regards to Fall Prevention and Fall Recovery..." 2. Review of E3's personnel record revealed no documentation indicating E3 completed fall prevention and fall recovery training. 3. During an interview, E1 acknowledged documentation was not available showing E3 had completed a training program for fall prevention and fall recovery.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for two of three employees. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution..." 2. Review of E2's personnel record revealed E2 worked as an assistant caregiver and had a hire date of June 1, 2023. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution. 3. Review of E3's personnel record revealed E3 worked as an assistant caregiver and had a hire date of June 1, 2023. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution. 4. During an interview, E1 acknowledged documentation was not available showing E2's and E3's work references were obtained upon hire at the facility.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented according to policies and procedures, for two of three employees. The deficient practice posed a risk if the employees were unable to meet a resident's needs Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Verifying Caregiver's Skills and Knowledge" reviewed and signed by E1 November 20, 2022. This policy stated "The manager will interview and assess the caregiver and test on caregiver skills using an assessment sheet.... the manager will put the assessment sheet....in the employee's files." 2. Review of E2's personnel record revealed E2 was hired as an assistant caregiver and had a hire date of June 1, 2023. The personnel record revealed no assessment sheet verifying E2's skills and knowledge. 3. Review of E3's personnel record revealed E3 was hired as an assistant caregiver and had a hire date of June 1, 2023. The personnel record revealed no assessment sheet verifying E3's skills and knowledge. 4. During an interview, E1 acknowledged E2's and E3's skills and knowledge were not verified and documented according to policy and procedure.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for one of three employees. The deficient practice posed a risk if the employees were unable to meet resident's needs. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "Employee Orientation and CEU's" reviewed and signed by E1 November 20, 2022. This policy stated "The Manager (or designee) is responsible for the training and orientation of all employees to enable them to perform the responsibilities of their jobs in an effective and efficient manner..." 2. Review of E3's personnel record revealed E3 was hired as an assistant caregiver and had a hire date of June 1, 2023. The personnel record revealed no documentation showing E3 had received orientation specific to the duties to be performed. 3. During an interview, E1 acknowledged documentation was not available showing E3 had received orientation specific to the duties to be performed.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During the facility tour with E1, the Compliance Officer observed Lorazepam and Bisacodyl suppositories unlocked in a box in the kitchen refrigerator. The box had a locking device, however the device was not locked. 2. During an observation, the caregivers were not accessing the medications at the time of arrival. 3. During an interview, E1 acknowledged medications were stored unlocked.