Comfort Home Assisted Living of Peoria, LLC

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for three of four residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. The Compliance Officer arrived at the facility around 11:45 am. 2. A review of R1's medical record revealed a service plan dated August 25, 2024. The service plan stated the following services were needed: "Oral Care: Requires Supervision, 2x daily and as needed" "Nail Care: Requires Assistance, daily and as needed" "Hair Care/shaving: Requires Assistance, comb daily and as needed" "Dressing: Requires Assistance" "Bathing: Requires Assistance, shower 2x every week and as needed" "Sponge bath: (caregivers on the 2x daily is not given)" "Toileting: Requires Assistance, brief change in bed daily as needed" "Daily Skin Check: CG (Caregiver)" "Encourage Fluid: 64 oz" However, documentation was not available indicating these services were provided October 20th - present. 3. A review of R2's medical record revealed a service plan dated September 05, 2024. The service plan stated the following services were needed: "Eating: Independent, 3x daily and snacks" ''Oral Care: Independent, 2x daily and as needed" ''Nail Care: Requires Assistance, daily and trim as needed" ''Hair Care/shaving: Independent, comb daily and as needed'' ''Dressing: Independent, 2x daily and as needed'' ''Sponge bath: CNA/facility staff on the days shower is not given'' ''Toileting: Independent, take to the restroom as needed'' "Daily Skin Check: CG" "Encourage Fluid: 64 oz" However, documentation was not available indicating these services were provided October 20th - present. 4. A review of R3's medical record revealed an activities of daily living (ADL) sheet for October 2024. The ADL sheet stated the following services were provided: "Encourage Fluid: 64 oz" "Full Bath: CG" "Shower bath: CG" "Oral Care AM/PM/PRN: CG" "Daily Skin Check: CG" ''Apply Daily Non-Medical Lotion: CG'' ''Assist with clothing: CG'' ''Comb Hair: CG'' ''Hand Nail Care: CG'' ''Incontinence Care: CG'' ''Personal Hygiene: CG'' ''Bowel Movement: CG'' However, the ADL sheet revealed no documentation the services were provided October 20th - present. 5. In an interview, E2 and E4 acknowledged R1's, R2's and R3's medical records did not include documentation of the above listed services October 20th - present, however, reported the services were provided as indicated in the service plan.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location 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 records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed one ambulatory resident. 3. During the environmental tour, the Compliance Officer observed the front door leading to the front yard. The door leading out to the front yard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the door was not secured and the door chime was turned off. 4. In an interview, E2 reported that the facility turns on the front door chime at night time. 5. In an interview, E2 and E4 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of four residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a current written service plan, which indicated R1 received medication administration. 2. A review of R1's medical record revealed signed medication orders dated August 09, 2024 for the following medications; - Aspirin Oral Tablet delayed release 81 MG Give 1 table by mouth one time a day - buPROPion HCI ER (SR) Oral Tablet Extended Release 12 Hour 150 MG Instructions: Give 1 tablet by mouth every 12 hours - Atorvastatin Calcium Oral Tablet 40 MG Give 1 tablet by mouth at bedtime - Furosemide Oral Tablet 20 MG Give 1 tablet by mouth one time a day - metFORMIN HCI Oral Tablet 500 MG Give 1 tablet by mouth two times a day - Metoprolol Tartrate Oral Tablet 25 MG Give 0.5 tablet by mouth every 12 hours - Sertraline HCI Oral Tablet 100 MG Give 1.5 tablet by mouth one time a day 3. A review of R1's medical record revealed a October 2024 medication administration record (MAR). This MAR did not include documentation that the aforementioned medications were provided on October 20th - present. 4. A review of R2's medical record revealed a current written service plan, which indicated R2 received medication administration. 5. A review of R2's medical record revealed signed medication orders for the following medications; - Aspirin Oral Tablet delayed release 81 MG Give 1 table by mouth one time a day - CARBIDOPA-LEVODOPA 1 Oral Tablet Q8H - Every Eight Hours - FLUOXETINE HCL 40 MG 1 Oral Capsule QD - One Time Daily - LATANOPROST OPHTHALMIC SOLUTION 0.005%. 1 Ocular (eye) Drops HS - At Bedtime - LISINOPRIL 20 MG 1 Tablet QD - One Time Daily 6. A review of R2's medical record revealed a October 2024 medication administration record (MAR). This MAR did not include documentation that the aforementioned medications were provided on October 20th - present. 7. In an interview, E2 and E4 reported the medications were administered per the medication orders and acknowledged R1's and R2's MAR's did not include documentation the medications were administered.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a health risk to the residents. Findings include: 1. During the environmental tour, the Compliance Officer observed the following on the kitchen counter: -An opened bottle of "Great Value Barbecue sauce" -An opened bottle of "LEE KUM LEE Hoisin Sauce" -An opened bottle of "Kikkoman Less Sodium Soy Sauce" -An opened bottle of "Lea & Perrins The Original Worcestershire Sauce" All of these containers stated "Refrigerate after opening". 2. In an interview, E2 and E4 acknowledged the potentially hazardous foods were not maintained at 41\'b0 F or below.

Based on observation and interview, the manager failed to ensure a first-aid kit was maintained in the assisted living facility in a location accessible to caregivers and assistant caregivers. Findings include: 1. The Compliance Officer requested E2 and E4 to provide the facility's first-aid kit. E2 reported that the facility did not have a first-aid kit. 2. In an interview, E2 and E4 acknowledged a first-aid kit was not available.

Based on observation, documentation review, and interview, the manager failed to ensure a smoke detector was in working order and tested at least once a month. The deficient practice posed a health and safety risk if the smoke detectors did not work properly during an emergency. Findings include: 1. During the environmental tour, the Compliance Officer observed that there was no fire alarm system. The Compliance Officer tested the smoke detectors in Bedroom 1, Living room hallway that was adjacent to the kitchen, and Bedroom 2, none of the devices were functional. 2. A review of the facility documentation revealed a Maintenance Log dated the year 2024, the last smoke detector testing was completed May 2024. 3. In an interview, E2 and E4 acknowledged the smoke detectors had not been tested monthly and the smoke detectors were not in working order.

Based on observation and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed one ambulatory resident. 3. During the environmental tour, the Compliance Officer observed the back yard, accessible by residents, were lined with several objects that obstructed the walkway and presented tripping hazards, including: empty large vases, 2 mattresses, a bed frame, boxes filled with household objects, trash, secured oxygen tank leaned against the back wall. 4. During the environmental tour, the Compliance Officer examined the medication storage cabinet located in the kitchen. While the cabinet was equipped with a locking mechanism, the Compliance Officer was able to open the door with minimal force. Due to the malfunctioning lock, medications stored within the cabinet were easily accessible to residents. 5. In an interview, E1 acknowledged the premises at the assisted living facility were not free from a condition or situation which may cause a resident or other individual to suffer physical injury.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection. Findings include: 1. During the environmental tour, the Compliance Officer observed multiple uncovered containers storing garbage and refuse in common bathrooms and resident bedrooms. 2. In an interview, E2 and E4 acknowledged the garbage and refuse were not stored in covered containers.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During the environmental tour, the Compliance Officer observed three small oxygen containers in a locked caregiver room (Bedroom 6). The oxygen containers were upright but not secured. 2. In an interview, E2 reported that the oxygen containers were theirs, and the containers were empty and waiting to be picked up by the supplier. 3. In an interview, E4 acknowledged the oxygen containers were not secured in an upright position. This is a repeat deficiency from the on-site compliance inspection conducted on December 20, 2021 and May 02, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area, labeled and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. The Compliance Officer observed one ambulatory resident. 3. During the environmental tour, the Compliance Officer observed a "Great Value Disinfectant spray" in the pantry along with food items. 4. During the environmental tour, the Compliance Officer observed an unlabeled poisonous or toxic material in a spray bottle in the counter of a common bathroom. 5. In an interview, E3 reported that the unlabeled poisonous or toxic material was a cleaning solution. 6. In an interview, E2 and E4 acknowledged poisonous and toxic materials stored by the assisted living facility were not maintained in a locked area, labeled and inaccessible to residents.

Based on observation and interview, the manager failed to ensure the bathroom accessible from a common area contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a potential risk to infection control. Findings include: 1. During the environmental tour, the Compliance Officer observed there were no paper towels in a dispenser or a mechanical air hand dryer available for two bathrooms in a common area used by residents, personnel and visitors. 2. In an interview, E2 and E4 acknowledged the bathrooms accessible from the common area did not contain paper towels in a dispenser or a mechanical air hand dryer.

Based on documentation review, record review, and interview, the administrator failed to ensure documentation required by Article 8 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. The Compliance Officer requested, on May 2, 2023 at 8:40AM, the following documentation to be provided to the Department: -E4's complete personnel record to include documentation cardiopulmonary resuscitation (CPR) training and first aid training; -R2's complete medical record to include a written service plan signed and dated by the resident or resident's representative; and -R3's complete medical record to include a written service plan signed and dated by the resident or resident's representative. However, not all required documentation was provided for review within two hours after a Department request. 2. The Compliance Officer requested, on May 2, 2023 at 9:39AM, the following documentation to be provided to the Department: -E4's complete personnel record to include documentation of CPR training and first aid training. However, not all required documentation was provided for review within two hours after a Department request. 3. In an interview, E5 acknowledged documentation required by Article 8 was not provided to the Department within two hours after a Department request and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) and first aid training, for one of four personnel members sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Cardiopulmonary Resuscitation" (dated July 18, 2022). The policy stated "1. Upon hiring, each new employee or volunteer is required to have CPR training specific for adults. A copy of CPR Certification of the front and back is to be kept in the employees personnel file and will renewed before the date of expiration." 2. A review of the facility's policies and procedures revealed a policy titled "First Aid" (dated July 18, 2022). The policy stated "3. A copy of First Aid Certification of the front and back is to be kept in the employees personnel file and will renewed before the date of expiration. 4. The current First Aid and expiration date will be documented in Employee Checklist upon hiring and will continue to be reviewed by the Manager." 3. The Compliance Officer requested, on May 2, 2023 at 8:40AM, the following documentation to be provided to the Department: -E4's complete personnel record to include documentation of CPR training and first aid training. However, the aforementioned documentation was not provided for review within two hours after a Department request. 4. The Compliance Officer requested, on May 2, 2023 at 9:39AM, the following documentation to be provided to the Department: -E4's complete personnel record to include documentation of CPR training and first aid training. However, the aforementioned documentation was not provided for review within two hours after a Department request. 5. A review of E4's (hired in March 2023) personnel record revealed E4 was hired as a caregiver. E4's personnel record revealed documentation of CPR training and first aid training was not available for review. 6. In an interview, E5 provided E4's documentation of CPR training and first aid training (issued April 5, 2021; expired April 5, 2023) via a picture on a smartphone at 12:01PM. 7. In an interview, E5 reported E4 has current documentation of CPR training and first aid training but was not maintained in E4's personnel record. 8. In an interview, E5 acknowledged E4's personnel record did not include documentation of current CPR training and first aid training. 9. In an email, received by the Department on May 2, 2023 at 3:40PM, E5 provided E4's current documentation of CPR training and first aid training.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, for two of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R2's medical record revealed a service plan for supervisory care services (dated in February 2023). However, R2's service plan was not signed and dated by R2 or R2's representative. 2. In an interview, E5 reported R2 would have excuses for not signing R2's service plan. 3. In an interview, E5 acknowledged R2's service plan was not signed and dated by R2 or R2's representative. 4. A review of R3's medical record revealed a service plan for supervisory care services (dated in February 2023). However, R3's service plan was not signed and dated by R3 or R3's representative. 5. In an interview, E5 acknowledged R3's service plan was not signed and dated by R3 or R3's representative.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed one ambulatory resident on premises. 2. The Compliance Officer observed an unlocked bedroom belonging to a caregiver. The Compliance Officer observed one bottle of "NyQuil Severe Cold & Flu." 3. In an interview, E5 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. This is a repeat deficiency from the on-site compliance inspection conducted on December 20, 2021.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. The Compliance Officer observed an oxygen container in an unoccupied resident bedroom. The oxygen container was upright but not secured. 2. In an interview, E5 acknowledged the oxygen container was not secured in an upright position. This is a repeat deficiency from the on-site compliance inspection conducted on December 20, 2021.

Based on observation and interview, the manager failed to ensure a swimming pool gate was locked when not in use. The deficient practice posed a drowning risk to residents. Findings include: 1. The Compliance Officer observed one ambulatory resident on premises. 2. The Compliance Officer observed a swimming pool on premises. The Compliance Officer observed the swimming pool was not in use. The Compliance Officer observed the swimming pool gate was not locked. 3. The Compliance Officer observed a padlock located next to the swimming pool gate and hanging on a life-preserver. 4. In an interview, E5 reported the swimming pool gate was always locked and acknowledged the swimming pool gate was not locked. This is a repeat deficiency from the on-site compliance inspection conducted on December 20, 2021.