Comfort Haven of Mesa

Based on documentation review and interview the licensee failed to ensure that the facility was annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1 . During a review of facility documents, the Compliance Officer observed tuberculosis testing for members and staff, however a facility risk of infectious Tuberculosis assessment, was not provided for review. 2 . In an interview, E1 acknowledged that the licensee failed to ensure there was an annual assessment for risk of exposure to infectious tuberculosis.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were established, documented, and implemented that cover job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees. Findings include: 1 . During a review of the facility documents, the Compliance Officer did not find a policy and procedure that required skills and knowledge checks prior to working with residents. 2 . While onsite, the Compliance Officer observed E3 working with residents. 3 . In an interview, E1 acknowledged that there was not a policy and procedure that covered job descriptions duties, and qualifications, including required skills and knowledge, education, and experience for employees.

Based on documentation review and interview, the manager failed to ensure that the policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1 . A review of facility policies and procedures revealed no documentation that the policies and procedures were reviewed by the manager within the past three years. 2 . In an interview, E1 acknowledged that the policies and procedures had not been reviewed withing the last three years.

Based on documentation review and interview, the manager failed to ensure that a documented report was submitted to the governing authority that included an identification of each concern about the delivery of services related to resident care and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. Findings include: 1 . A review of facility documents revealed that the facility did not have a Quality Management program per R9-10-804.2.a-b, to address the delivery of services related to resident care. 2 . In an interview, E1 reported that they did not have a Quality Management program and that the facility used progress notes in the resident service plans, as quality management.

Based on record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented. Findings include: 1 . A review of employee files revealed orientation to the facility, however, there were no skills and knowledge verification for three of three employees sampled. 2 . In an interview, E1 reported that the manager failed to ensure that a caregiver's skills and knowledge were verified and documented.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility that included whether the individual requires continuous medical services, continuous or intermittent nursing services or restraints and was signed by a physician, registered nurse practitioner, registered nurse or physician assistant. 1 . A review of R1's, R2's and R3's files revealed no 90 day determination form for the Compliance Officer to review, at the time of inspection, for the residents sampled. 2 . In an interview, E1 acknowledged that the manager failed to obtain a document that was dated within 90 calendar days before admission, of an individual, which stated that the individual required either: continuous medical services, continuous or intermittent nursing services or restraints.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance there was a documented residency agreement with the assisted living facility to include whether the manager or a caregiver is awake during nighttime hours, for two of two residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1's medical record revealed a residency agreement (dated February 2021). However, the residency agreement did not include whether the manager or a caregiver was awake during nighttime hours. 2. A review of R2's medical record revealed a residency agreement (dated February 2009). However, the residency agreement did not include whether the manager or a caregiver was awake during nighttime hours. 3. In an interview, E1 acknowledged the documented residency agreements for R1 and R2 did not include whether the manager or a caregiver was awake during nighttime hours.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, 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 and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility 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. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During a tour of the facility with E1 and E2, the Compliance Officer observed when exiting from the patio door to the backyard, no alarm sounded to alert employees of the egress of a resident from the facility. 3. During a tour of the facility with E1 and E2, the Compliance Officer observed when exiting from the front door to the front yard, no alarm sounded to alert employees of the egress of a resident from the facility. The Compliance Officer observed an alert system was installed on the patio door. However, the alert system was not functioning. 4. During a tour of the facility with E2, the Compliance Officer observed the aforementioned doors allowed residents to be at least 30 feet away from the facility. 5. In an interview, E2 acknowledged the aforementioned doors did not alert employees of the egress of a resident from the facility.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures for medication administration were implemented for documenting medication administration. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Recording of Medication and Assistance." The policy stated, "All medication requirements will be documented based on doctor's orders. Daily written records will be maintained providing name of resident, medication, date and time of administering, date and time of assistance, and signature of staff. Medication Administration Records are maintained and stored in the staff office in a designated notebook." 2. A review of R2's record revealed a current written service plan dated June 30, 2023. The service plan indicated R2 received medication administration. 3. A review of R2's medical record revealed a signed medication list dated May 1, 2023. The medication list included the following: -Multivite, 1 tab by mouth QAM; -Simvastatin 20 mg, 1 tab by mouth QD in the evening; -Bisoprolol/HCTZ 10 mg/6.25 mg, 1 tab by mouth QD; -Finasteride 5 mg, 1 tab by mouth QD; -Seroquel 200 mg, 1 tab by mouth QHS; -Exelon Patch 9.5/24 hrs 1 patch applied topically QD. Rotate site per package instructions; -Namenda XR 28 mg, 1 tab by mouth QD; -Clonidine HCL 0.2 mg, 1 tab by mouth BID; -Sinemet (Carbidopa-Levidopa) 25/250 mg, 1 tab by mouth QID; -Hydralazine 100 mg, 1 tab by mouth BID; -Comtan 200 mg, 1 tab by mouth TID; -Ativan 0.5 mg, 1 tab by mouth QD and QD PRN; -Neurontin 300 mg, 1 tab by mouth TID; -Cymbalta 60 mg, 1 tab by mouth QAM; -Folic Acid 1 mg, 1 tab by mouth QD; -Fiber Therapy Tablets 500 mg, 1 tab by mouth QD -Lamictal 25 mg, 2 tabs by mouth BID; -Metformin HCl 500 mg, 1 tab by mouth BID with a meal; -Vitamin D 2000 UT, 1 cap by mouth QD; -Primidone 50 mg, 1 tab by mouth BID; -Gemtesa 75 mg, 1 tab by mouth QD; and -Tamsulosin 0.4 mg, 1 tab by mouth QD. 4. A review of R2's August 2023 medication administration record (MAR) revealed the time of medication administration was documented as "Dinner Meds" for the following medications: -Clonidine HCL 0.2 mg, 1 tab by mouth BID; -Comtan 200 mg, 1 tab by mouth TID; -Lamictal 25 mg, 2 tabs by mouth BID; -Simvastatin 20 mg, 1 tab by mouth QD in the evening; -Metformin HCl 500 mg, 1 tab by mouth BID with a meal; and -Gemtesa 75 mg, 1 tab by mouth QD. However, the actual time of medication administration was not documented. 5. In an interview, E2 acknowledged the facility's policies and procedures were not implemented for documenting medication administration as the time of medication administration was not documented.