Comfort Home Care LLC

Based on documentation review and interview, the health care institution failed to develop and administer a training program regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of facility documentation revealed a fall prevention and fall recovery training program was not available for review. 2. In an interview, E1 reported E1 has a program/policy for fall prevention and fall recovery but was not able to provide it for review while the Compliance Officers were on-site. E1 acknowledged a fall prevention and fall recovery training program was not available for review at the time of the inspection.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that were present each day to ensure the health and safety of residents. Findings include: 1. Upon arrival to the facility, the Compliance Officers observed E1 arrive at the facility. Upon entering the facility with E1, the Compliance Officers observed E2 and E3 providing care to the residents. 2. A review of facility documentation revealed personnel schedules for the months of September 2024 and October 2024. The Compliance Officers requested to see the personnel schedule for the month of November 2024; however, E1 was not able to provide the documentation. 3. In an interview, E1 acknowledged documentation was not maintained of the caregivers working each day, including the hours worked for the month of November 2024.

Based on record review, documentation review, and interview, the manager failed to ensure that a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) and first aid (FA) training, for one of two personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E3's personnel file revealed a CPR/FA card that expired on August 26, 2024. Documentation of current CPR/FA training was not available for review at the time of the inspection. 2. A review of facility documentation revealed a policy titled "First Aid and CPR Training." The policy stated, "In order to keep First Aid and CPR training and skills up to date, it is required that each employee and volunteer to provide the following: 1. Documentation that verifies that the employee or volunteer has received CPR and First Aid training. 2. Method and content of CPR training which includes the ability to perform and demonstrate cardiopulmonary resuscitation. 3. Timeframe for renewal of training for CPR and First Aid." 3. In an interview, E1 acknowledged E3's personnel record did not contain documentation of current CPR/FA training at the time of the inspection.

Based on documentation review, 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 of the resident's admission to the facility, and as specified in R9-10-113, for two of two residents sampled. 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, baseline 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. A review of R1's medical record revealed a TB PPD Skin Test upon admission; however, there was no documentation of the assessment of prior exposure to TB or determining if R1 had signs or symptoms of TB. 3. A review of R2's medical record revealed a TB PPD Skin Test and documentation of the assessment of prior exposure to TB or determining if R2 had signs or symptoms of TB; however, the TB PPD Skin Test and assessment had not been conducted before or within seven calendar days of R2's admission into the facility. 4. In an interview, E1 reported E1 thought the time frame for conducting a TB test for new admissions was 14 days. E1 acknowledged R1's medical record did not contain documentation of assessment of prior exposure to TB or the determination of signs or symptoms. E1 also acknowledged R2's TB test was not conducted before or within seven calendar days after R2's date of admission.

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. While on-site, the Compliance Officers observed one ambulatory resident. 3. During the environmental tour, the Compliance Officers observed a sliding glass door leading to the backyard. The door had a device that was intended to alert employees of the egress of a resident to the outside area; however, the door chime was turned off. 4. A review of facility documentation revealed a policy titled "Wandering." The policy stated, "5. If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security." 5. In an interview, E1 reported E1 thought the sliding glass door alarm leading to the backyard only had to be turned on at night. E1 acknowledged at the time of the inspection 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, documentation review, and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record for two of three 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 and R3's medical record revealed R1 and R3 received medication administration. 2. A review of R1's medical record revealed a signed medication list (dated October 8, 2024) that included the following medications: - Trazodone 100 milligrams (mg), 1 tablet (tab) every night at bedtime (QHS); - Citalopram 10 mg, 1 tab once a day in the morning (QAM); - Haldol 2 mg/milliliter (ml), take 0.5 mg twice a day (BID); - Haldol 2 mg/ml, take 0.5 mg BID as needed (PRN); - Haldol 2 mg/ml, take 1 mg QHS; and - Tylenol 500 mg every 4 hours PRN. 3. A review of R1's medical record revealed a medication administration record (MAR) for November 2024. However, the following medication was not documented as administered on the following dates and times: - Trazodone 100 mg, 1 tab QHS: November 1, 2024-November 3, 2024 at 8:00 PM. 4. A review of R3's medical record revealed a signed medication list (dated September 25, 2024) that included the following medications: - Lamotrigine 100 mg, 1.5 tab BID; - Aripiprazole 15 mg, 1 tab every night QHS; - Levetiracetam 500 mg, 1 tab BID; - Solifenacin 5 mg, 1 tab QHS; - Eliquis 5 mg, 1 tab BID; - Oxcarbazepine 300 mg, 1 tab BID; - Vitamin D 3 1000 mg, 1 capsule (cap) QD; - Omeprazole 20 mg, 1 cap QD; - Acidophilus 1 cap QD; - Atorvastatin 20 mg, 1 tab QD; - Tums 500 mg, chew tab QD; - Doxycycline 100 mg, 1 cap BID; - Senna S 8.6 mg, 2 tab QD; - Melatonin 5 mg, 1 cap QHS; - Estradiol cream 0.01%, insert 1 gram (g) vaginally twice a week Monday & Thursday QHS; - Ondansetron 4 mg, 1 tab on top of tongue three times a day (TID) PRN; - Tylenol 500 mg, 2 tab BID PRN; - Miralax 3350 Powder, Mix 17 g in fluids QD PRN; - Nystatin Powder 100,000 Units (u), apply topically to affected area BID PRN; and - Methocarbamol 500 mg, 2 tab 4 times(x) a day PRN. 5. A review of R3's medical record revealed a MAR for November 2024. However, the following medication was not documented as administered on the following dates and times: - Levetiracetam 500 mg, 1 tab BID: November 3, 2024 at 8:00 PM; - Solifenacin 5 mg, 1 tab QHS: November 1, 2024-November 3, 2024 at 8:00 PM; - Oxcarbazepine 300 mg, 1 tab BID: November 1, 2024-November 3, 2024 at 8:00 PM; - Omeprazole 20 mg, 1 cap QD: November 1, 2024-November 3, 2024 at 8:00 PM; - Atorvastatin 20 mg, 1 tab QD: November 1, 2024-November 3, 2024 at 8:00 PM; - Doxycycline 100 mg, 1 cap BID: November 1, 2024-November 3, 2024 at 8:00 PM; and - Melatonin 5 mg, 1 cap QHS: November 1, 2024-November 3, 2024 at 8:00 PM. 6. A review of the facility's policies and procedures revealed a policy titled "Medication Services." The policy stated, "22. The tr

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 a risk to residents who were not prescribed the accessible medication. Findings include: 1. During the environmental tour with E1, the Compliance Officers observed an unlocked bedroom door marked "Personel [sic]." Inside the room the Compliance Officers observed the following medications: - Advil Dual Action with Acetaminophen 250 milligrams (mg); - Prednisone 50 mg tablet prescribed to R3; - Vicks Vapo Steam; - Robitussin Cough+Chest Congestion DM; - Pantoprazole SOD DR 40 mg tab; - Prednisone 10 mg tab prescribed to a previous resident; - Lorazepam Intensol Oral Concentrate 2 mg per milliliter with an oral syringe; and - Acetaminophen PM. 2. In an interview, E1 reported E2 and E3 are live-in caregivers and share the bedroom. E1 reported either E2 or E3 had just been in the room and didn't lock it upon exiting. E1 reported E1 was unaware of the medication found in the caregivers' room. E1 acknowledged E1 failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. 3. This is a repeat deficiency from the compliance inspection conducted May 2, 2023.

Based on observation, documentation review, and interview, when medication was stored by an assisted living facility, the manager failed to ensure that policies and procedures were implemented for inventorying, tracking, and discarding medication including expired medication. Findings include: 1. During the environmental tour with E1, the Compliance Officers observed a clear Tupperware tote containing medication labeled "Manager Only" in a locked cabinet. Inside the tote were 36 bottles/boxes/packages of medication from eight different residents, two of which were current residents. 2. A review of facility documentation revealed a policy titled "Medication Services." The policy stated, "21. Any resident ' s medication discontinued by the physician, expired medication, including deceased resident ' s medication shall be offered back to the resident ' s representative, returned to the pharmacy or disposed of by mixing the pill with hot water and cooking flour (coffee grinds or kitty litter may be used if cooking flour not available), closing the container 's lid on securely and shake. Then scrape the label off the container and toss in trash. Documentation and proof of return or destruction of medications including narcotics will be maintained...". 3. In an interview, E1 reported that most of the medication was from previous residents, except for the two current residents, in which that medication had been discontinued or was expired. E1 reported E1 had intended to dispose of the medication but hadn't done so yet. E1 disposed of the all the medication in the kitchen while the Compliance Officers were on-site. E1 acknowledged E1 failed to ensure that policies and procedures were implemented for discarding medication including expired medication.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the facility quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Quality Management Program" reviewed and signed by E2 July 15, 2020. This policy stated "...11. Once a month the manager will report to the governing authority/licensee all the concerns about the delivery or services related to the resident's care and any changes made or action taken as a result of the identification of a concern about the delivery of services related to resident's care..." 2. Review of the quality management program documentation revealed the last quality management report was generated February 2023. 3. During an interview, E1 acknowledged the quality management report was not submitted per the frequency established in the quality management program.

Based on documentation review, record review, and interview, the manager failed to ensure the policy and procedure and a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G), for two of two residents reviewed accepted by the assisted living facility on or after October 1, 2019. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Rule review of R9-10-807(G) on or after October 1, 2019 stated: "A manager may terminate residency of a resident as follows: 1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility; 2. With a 14 calendar day written notice of termination of residency: a. For nonpayment of fees, charges or deposits; or b. Under any of the conditions in subsection (C); or 3. With a 30 calendar day written notice of termination of residency, for any other reason." Review of subsection (C) stated: "1. The individual requires continuous: a. Medical services; b. Nursing services unless the assisted living facility complies with A.R.S.36-401(C); or c. Behavioral Health Services; 2. The primary condition for which the individual needs assisted living services is a behavioral health issue; 3. The assisted living services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual; 4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 5. The individual requires restraints, including the use of bedrails." 2. Review of the facility's policy and procedure revealed a policy titled "Termination of Residency Agreements" reviewed and signed by E2 July 15, 2020. This policy stated: "1. The management will provide the resident or resident's representative 30 days written notice before terminating the resident's Residency Agreement except in the following circumstances: a. The management will terminate the resident's Residency Agreement without notice if: i. The resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility; b. The management will terminate the resident's Residency Agreement after providing 14 days written notice to a resident or the resident's representative for one of the following reasons: i. Documented failure to pay fees, charges or deposits; or ii. The individual requires continuous medical services, nursing services, (unless the facility complies with A.R.S.36-401(C); or behavioral health services; iii. The assisted living services needed by the individual are not within the assisted living facility's scope of services; iv. The facility does not have the ability to provide the assisted living services needed by the ind

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 R2's medical record revealed a current written service plan dated March 3, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated March 10, 2023. This medication order stated "Venlafaxine 25mg 1 tab QD". In addition, R2's medication record revealed a signed medication order dated March 16, 2023. This medication order stated "Glipizide 15mg daily". 3. Review of R2's medical record revealed a May 2023 medication administration record (MAR). This MAR stated the following: "Venlafaxine 25mg 1 tab QD PO" and indicated one tab was administered at 8am May 1st - present. "Glipizide 15mg 1 tab BID PO" and indicated one tab was administered at 8am and 8pm May 1st - present. 4. During an observation of R2's medications, the following was observed: Venlafaxine 50mg was observed. Glipizide 10mg was observed and one tab was observed prefilled in the "Morning" and "Bedtime" slot of R2's medication organizer 5. During an interview, E1 reported Venlafaxine 50mg was administered every morning and Glipizide 10mg was administered two times a day and acknowledged R2's medications were 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. Findings include: 1. Review of R1's medical record revealed a current written service plan dated March 3, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated April 21, 2023. This medication order stated "Atorvastatin 20mg 1 tab daily". 3. Review of R1's medical record revealed a May 2023 medication administration record (MAR). This MAR did not include documentation Atorvastatin 20mg was administered May 1st - present. 4. During an observation of R1's medications, Atorvastatin 20mg was observed and one tab was observed prefilled in the "Bedtime" slot of R1's medication organizer. 5. During an interview, E1 reported one tab of Atorvastatin 20mg was administered per the medication order and acknowledged R1's medical record did not include documentation the medication was 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. When the Compliance Officer arrived, the medication cabinet in the kitchen that held nine residents' medications was observed unlocked. The cabinet had a locking device, however the key was stored in the device. 2. During an observation, E3 and E4 were the only employee at the facility when the Compliance Officer arrived and were not accessing the medications at the time of arrival and left the immediate area multiple times, leaving the cabinet unlocked. 3. During an interview, E1 acknowledged medications were stored unlocked.

Based on documentation review and interview, the manager failed to ensure documentation of each evacuation drill included the amount of time taken for employees and residents to evacuate the assisted living facility. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. Review of the evacuation drills revealed drills conducted July 7, 2022, October 6, 2022, and January 6, 2023. However, these drills did not include the amount of time taken for employees and residents to evacuate the assisted living facility. 2. During an interview, E1 acknowledged the evacuation drills did not include the amount of time taken for employees and residents to evacuate the assisted living facility.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the action taken to prevent the incident from occurring in the future, for one of one resident reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R2's medical record revealed a document titled "Incident/Unusual Occurrence Report" dated April 17, 2023. This document stated "...was using the toilet and while pulling (R2's) pants down (R2) bended to much forward and fell hitting (R2's) forehead on the tiles on the bathroom floor...Doctor came to see (R2) on 4/19...X-ray negative of bleeding or fractures..." However, the documentation did not include the action taken to prevent the incident from occurring in the future. 2. During an interview, E1 acknowledged R2's medical record did not include documentation of the action taken to prevent the incident from occurring in the future.