Luxury Comfort Home

Based on documentation review, record review, and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04.A. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives." 2. A review of facility documentation did include a standardized form; however, it did not include the aforementioned information for each resident of the facility. 3. A review of R1's and R2's medical records revealed all required information; however, a standardized form with all aforementioned information was not available for review. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 5. Technical assistance was provided regarding this rule during the compliance inspection conducted on October 19, 2023.

Based on documentation review, observation, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for two of two personnel sampled. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(2) states, "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card." 2. A.R.S. § 36-411(C)(3) states: "3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee." 3. The Compliance Officer observed E2 working at the time of the inspection. 4. A review of the Arizona Department of Public Safety Fingerprint Clearance Status website revealed E1 and E2 currently had valid fingerprint clearance cards. However, there was no documented verification of E1’s and E2’s fingerprint clearance cards within E1’s and E2's personnel records. 5. A review of E1’s and E2’s personnel records did not include documentation that E1 and E2 were not on the adult protective services registry pursuant to section 46-459. 6. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a quality management plan was documented for an ongoing program which included the frequency of submitting a documented report required in subsection (2) to the governing authority. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of facility documentation revealed the last quality management report was created and dated in July 2025. There were no other documents to be viewed for the months after July 2025. 2. A review of the facility policy and procedures revealed a policy titled, “Quality Management Program, Including Incident Reports,” which stated, “11. Once a month the manager will report to the governing authority/ licensee all the concerts about the delivery of services related to a resident’s 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.” 3. In an interview, E2 acknowledged that the last quality management report was in July 2025. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 5. Technical assistance was provided regarding this rule during the compliance inspection conducted on October 19, 2023.

Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included terms of occupancy, including the date of occupancy or expected date of occupancy, for one of two sampled residents. Findings include: 1. A review of R1’s medical record revealed no date of occupancy or expected date of occupancy on R1’s residency agreement. 2. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 3. Technical assistance was provided regarding this rule during the compliance inspection conducted on October 19, 2023.

Based on documentation review and interview, the manager failed to ensure that 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 a disaster plan. Findings include: 1. A review of facility documentation revealed a disaster drill was completed on July 7, 2025 for the second shift and on July 8, 2025 a disaster drill was completed for the first shift. However, documentation of additional disaster drills was not available for review. 2. A review of facility documentation revealed that the facility had two personnel shifts. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of facility documentation revealed an evacuation drill was completed January 1, 2025. There was no other documentation of an evacuation drill completed after January 2025. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

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 that included continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of facility documentation revealed no documentation of a training program for all staff regarding fall prevention and fall recovery. 2. Review of E1's personnel record revealed E1 worked as a caregiver and had a hire date of January 8, 2005. The personnel record revealed documentation of fall prevention training dated June 1, 2022. However, current documentation was not available indicating E1 completed fall prevention and fall recovery training. 3. Review of E2's personnel record revealed E2 worked as the manager and had a hire date of April 13, 2023. The personnel record revealed documentation of fall prevention training dated April 29, 2022. However, current documentation was not available indicating E2 completed fall prevention and fall recovery training. 4. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of November 28, 2005. The personnel record revealed documentation of fall prevention training dated July 6, 2022. However, current documentation was not available indicating E3 completed fall prevention and fall recovery training. 5. In an interview, E1 acknowledged documentation was not available that showed E1, E2, and E3 completed current training for fall prevention and fall recovery.

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.

Based on record review and interview, the manager failed to ensure a residency agreement included whether the manager or a caregiver was awake during nighttime hours, for one of two residents reviewed accepted by the assisted living home on or after July 1, 2014. The deficient practice posed a health and safety risk if a resident was unable to awaken the caregivers during nighttime hours. Findings include: 1. Review of R1's medical record revealed a residency agreement. However, this residency agreement did not include documentation of whether the manager or a caregiver was awake during nighttime hours. Based on R1's acceptance date, this documentation was required. 2. In an interview, E1 reported caregivers sleep at night and wake up if the residents need assistance. E1 acknowledged R1's residency agreement did not include that information.

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 one of two resident 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 of review R9-10-807(G) on or after October 1, 2019 and the facility's policy and procedure titled "Termination of Residency Agreements" 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: "C. A manager shall not accept or retain an individual if: 1. The individual requires continuous: a. Medical services; b. Nursing services, (unless the facility complies with A.R.S.36-401(C); or c. Behavioral Health Services; 2. The assisted living services needed by the individual are not within the assisted living facility's scope of services; 3. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 4. The individual requires restraints, including the use of bedrails. 3. With a 30 calendar day written notice of termination of residency, for any other reason..." 2. Review of R1's medical record revealed a residency agreement. This residency agreement did not include the correct provisions allowing a manager to terminate residency of a resident. The residency agreement did not include the following terms for a 14 day termination: -The primary condition for which the individual needs assisted living services is a behavioral health issue; and -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. Based on R1's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged the facility's policy and procedure and R1's residency agreement did not include the correct policy and procedure for an assisted living facility to terminate residency.