Comfort Assisted Living Home, LLC

Based on record review and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9), for three of three sampled residents. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed standardized emergency responder forms were not available for review. 2. In an interview, E1 acknowledged medical records for R1, R2, and R3 did not contain standardized emergency responder forms as required by this statute. E1 was provided with a copy of the statute for review.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for one of three employees reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E1's personnel record revealed E1 was hired as a manager prior to 2023; however, E1 completed one tuberculosis skin test in 2023 and 2024 which is not in compliance with current two step skin or 1 blood testing as required. No other documentation was available for review to show E1 had any TB testing or baseline screening conducted prior to providing services at or on behalf of the assisted living facility according to R9-10-113(B)(1). 4. In an interview, E1 acknowledged E1 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date the individual began providing services at or on behalf of the assisted living facility.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a complete personnel record was available for one of three employees reviewed. The deficient practice posed a risk as the Department was provided false information. Findings include: 1. Upon arrival, the Compliance Officer observed E1 and E3 working at the facility. 2. A review of personnel records revealed no record for E3. E1 reported that the personnel record for E2 was the record for E3. 3. In an interview, E1 reported that E3 was E2. E3 did not respond when addressed by E2's name and was unable to provide the middle name for E2. 4. In an interview, E1 reported E3 was not E2 as previously reported to the Compliance Officer and E2 was no longer employed for the facility. 5. In an interview, E3 provided documentation of a passport which verified that E3 was not E2. 6. In an interview, E1 acknowledged that a personnel record was not availble for E3.

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy, and as specified in R9-10-113, for three of three residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed no evidence of freedom of TB before or within seven calendar days after R1's, R2's, and R3's dates of acceptance. 2. In an interview, E1 acknowledged R1's, R2's, R3's medical records did not contain evidence that TB testing or screening was conducted before or within seven calendar days after R1's and R2's dates of admission.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's service plan and updates for one of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not provided during the inspection. Findings include: 1. A review of R1's medical record revealed R1's level of care was initially personal care services; however, in July 2023, R1 was placed on directed care which required service plan reviews at least every three months. 2. A review of R1's medical record revealed service plans dated July 2023, October 2023, January 2024, and July 2024. A service plan for April 2024 was not available for review. 3. In an interview, E1 reported that an error was made and the service plan update for April of 2024 was not conducted. E1 confirmed this information with the company that conducts the service plans for this facility. 4. In an interview, E1 acknowledged that R1's medical record did not contain service plan updates that were conducted at least every three months as required.

Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of notification of the availability of vaccination for influenza and pneumonia offered to residents on a yearly basis, according to A.R.S. \'a7 36-406(1)(d), for one of three residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of R1's medical record revealed no documentation for 2022 or prior was available for review to show that notification of the availability or refusal of vaccination for pneumonia was offered to R1 on a yearly basis based on R1's date of acceptance. 2. In an interview, E1 acknowledged R1's medical record did not include documentation of notification of the availability or refusal of vaccination for pneumonia on a yearly basis.

Based on documentation review, observation, and interview for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted 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. A review of the license issued by the Department revealed the facility was licensed at the directed care level. 2. The Compliance Officer observed a living room/dining room door exiting to the backyard to have an alert; however, it was non-functional and did not control or alert employees of the egress of a resident. 3. During an interview, E1 reported that the door alarm had been previously replaced and E1 was not sure why the alarm was not working. E1 made attempts while the Compliance Officer was onsite to repair the alarm; however, the alarm still did not work before the Compliance Officer left the facility. E1 reported that the alarm would be repaired the following day. 4. During an interview, E1 acknowledged the backdoor provided access to the outside and did not control or alert employees of the egress of a resident from the facility. This is a repeated citation from the compliance inspection conducted on October 7, 2022.

Based on observation, record review, and interview for one of three residents reviewed; the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a manager or caregiver did not document a medication was administered. Findings include: 1. In observation, R1's medications were observed on-site and Miralax 17g was not included in R1's medication bin. 2. A review of R1's medical record (received directed care and medication administration services) included a medication order for Miralax 17g to be given one time a day. 3. A review of R1's medication administration record (MAR); documented that Miralax 17g had been administered once a day at 8:00 am from November 1, 2024 - November 12, 2024; however, the physical medication for Miralax was not available for review during this inspection. 4. During an interview, E1 reported R1 ran out of Miralax 17g and E1 is not sure when R1 was last administered this medication. E1 acknowledged that the MAR documented that Miralax 17 g was administered to R1 each day in the month of November 2024; however, E1 confirmed that this was incorrect as this medication was not present/available to be administered. 5. During an interview, E1 acknowledged the medication administration was not documented accurately as required.

Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures were implemented for storing medication. The deficient practice posed a health risk to a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Discarding Medication." This document stated "Any resident medication, which is discontinued or expired by medical practitioner's order, shall be offered back to the resident's representative, resident family member, returned to pharmacy, returned to Hospice, or disposal of medications will be performed according to Arizona's Department of Environmental Quality brochure." 2. The Compliance Officer observed Senna 8.6 mg in R2's medication storage bin. The medication expired on 10/22/2024 and had not be disposed of per policies and procedures. 3. During an interview, E1 acknowledged the facility did not discard the medications per the facility's policy and procedure on discarding medications.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. A review of the November 2024 personnel schedule revealed two shifts: 6:00 am - 6:00 pm and 6:00 pm - 6:00 am. 2. A review of the facility's employee disaster disaster drills revealed disaster drills conducted on the following dates and times: -March 16, 2024 at 10:00 am -June 16, 2024 at 9:30 am -September 16, 2024 at 10:00 am 3. In an interview, E1 acknowledged a disaster drill for employees was not conducted and documented on each shift at least once every three months.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after acceptance, for one of three residents sampled. Findings include: 1. A review of R1's medical record revealed an orientation form signed on January 2, 2022. Based on R1's acceptance date, the orientation was not provided within 24 hours after R1's acceptance. 3. In an interview, E1 acknowledged R1 did not have proper documentation of being oriented to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after acceptance.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents reviewed. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of R1's medical record revealed no documentation of assessing risk of prior exposure to infectious TB or determining if the R1 had signs or symptoms of TB. Based on R1's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R1 did not provide documentation of assessing risk of prior exposure to infectious TB or determining if R1 had signs or symptoms of TB. 4. Technical assistance was provided on this Rule during the compliance inspection conducted October 7, 2022.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two residents reviewed accepted by the assisted living facility on or after October 1, 2013. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R1's medical record revealed no documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1's acceptance date, this documentation was required. 2. In an interview, E1 acknowledged R1 did not provide documentation signed by a medical practitioner or a registered nurse stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 3. This is a repeat deficiency from the compliance inspection conducted October 7, 2022.

Based on record review and interview, the manager failed to ensure the facility did not accept a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, upon acceptance and every six months thereafter, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R1's medical record revealed a current written service plan for personal care services dated September 7, 2023. This service plan stated "Transfer assistance - 2 person". 2. Review of R1's medical record revealed no documentation indicating R1's medical practitioner examined R1 upon acceptance and every six months thereafter, signed and dated a determination stating R1's needs could be met by the facility, and reviewed the facility's scope of services. 3. In an interview, E1 reported R1 was unable to ambulate even with assistance since acceptance and acknowledged R1's medical practitioner did not provide a written determination upon acceptance and every six months thereafter. 4. This is a repeat deficiency from the compliance inspection conducted October 7, 2022.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and controlled or alerted 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. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility with E1, the Compliance Officer observed the door exiting to the backyard did not have a device that alerted employees to the egress of a resident to the outside area. 3. In an interview, E1 acknowledged there was a means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility. 4. Technical assistance was provided on this Rule during the compliance inspection conducted October 7, 2022.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated September 7, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated September 12, 2023. This medication order stated "Gabapentin 300mg oral capsule - take one cap PO every 8 hours". 3. Review of R1's medical record revealed a September 2023 medication administration record (MAR). This MAR stated "Gabapentin 300mg PO BID" and indicated one tab was administered at 8pm and 5pm September 1st - present. 4. During an observation of R1's medications, Gabapentin 300mg was observed and one tab was observed prefilled in the "Morning" and "Evening" slot of R1's medication organizer. 5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R1's medication was not administered in compliance with the available medication order.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order and posed a risk as the medical record inaccurately indicated a medication was administered. Findings include: 1. Review of R1's medical record revealed a current written service plan dated September 7, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication order dated September 12, 2023. These medication orders stated the following: "Calmoseptine 0.44%-20.6% topical ointment - apply topically at perineal area twice a day" "Fenofibrate 54mg oral tablet - take one tab PO QHS" 3. Review of R1's medical record revealed a September 2023 medication administration record (MAR). This MAR stated the following: Calmoseptine was not include on the MAR "Fenofibrate 54mg 1 tab PO QHS" and indicated 1 tab was administered at 8am and 5pm September 1st - present 4. During an observation of R1's medications, the following was observed: Calmoseptine was observed Fenofibrate 54mg was observed and one tab was observed prefilled in the "Evening" slot of R1's medication organizer. 5. In an interview, E1 reported the medications were administered per the medication orders and acknowledged R1's medical record did not include accurate documentation the medications were administered.

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 an environmental inspection of the facility with E1, the Compliance Officer observed the medication cabinet that held seven residents' medications unlocked. The cabinet had a locking device that was broken. 2. During an observation, the caregivers were not accessing the medications at the time of arrival. 3. In an interview, E1 acknowledged medications were stored unlocked.

Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. Review of facility's documents revealed no policy and procedure that covered TB infection control activities. 2. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of July 2013. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. In an interview, E1 acknowledged E1 had not completed training and education related to recognizing the signs and symptoms of TB. 4. Technical assistance was provided on this Rule during the compliance inspection conducted October 7, 2022.

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility's documents revealed no policy and procedure that covered TB infection control activities. 2. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB. 3. In an interview, E1 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 4. Technical assistance was provided on this Rule during the compliance inspection conducted October 7, 2022.