PREMIUM COMFORT CARE

INSP-0158765

Complete

Date: 9/2/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-09-08

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on September 2, 2025:

Deficiencies Found: 9

Deficiency #1

Rule/Regulation Violated:

R9-10-113.A.2.a-f. Tuberculosis Screening A. 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); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on record review, documentation 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, for one of three personnel records sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of E2’s personnel revealed no documentation of annual training related to recognizing the signs and symptoms of TB. Based on E2’s hire date, this documentation was required. 2. A review of the facility's policies and procedures revealed a policy titled “Tuberculosis (“TB”) Testing.” The policy stated, “The facility provides in-service training and education related to recognizing and symptoms of tuberculosis yearly.” 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Temporary Solution:

The missing TB and Fall Prevention training records were immediately located and placed in the appropriate employee personnel files for review and verification.

Permanent Solution:

To prevent this issue from happening again, the facility has implemented a new tracking application that automatically monitors and reminds staff and management of all upcoming training deadlines. Calendar reminders have also been set up for the manager and administrator to ensure annual trainings are verified before the due date. All training records will now be stored directly in each employee’s personnel file.

Person Responsible:

E2 – Facility Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-803.A.8. Administration A. A governing authority shall: 8. Ensure that a manager or caregiver who is able to read, write, understand, and communicate in English is on an assisted living facility’s premises;

Evidence/Findings:

Based on observation, interview, record review, and documentation review, the governing authority failed to ensure a caregiver who was able to read, write, understand, and communicate in English was on the assisted living facility's premises. The deficient practice posed a risk if the caregiver was unable to understand and communicate with residents, others involved in resident care, the Department, and emergency services. Findings include: 1. Upon arrival at the facility, E3 reported E3 did not speak or understand English. E3 went to get E1. 2. During an interview, E1 reported E3 was not good with English. 3. The Compliance Officers (COs) observed E3 working at the facility with seven residents present. 4. During an interview, E3 reported E3 did not speak English and did not understand the COs questions. E3 would have E1 answer the questions. 5. E1 reported E1 worked as an assistant caregiver. 6. A review of E3's personnel record revealed E3 worked as a caregiver. 7. During an environmental inspection, the COs observed the manager designation documentation posted at the front door with E3’s name and signature. 8. A review of the August 2025 personnel work schedule revealed E3 was scheduled for every day in August. 9. In an interview, E2 reported that E3 was E2's manager designee. 10. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Temporary Solution:

Following the inspection, E3 was immediately removed from her role as manager designee until her English communication skills improve to an adequate level. She was provided with additional training and language support before returning to work. The facility ensured that an English-proficient caregiver or manager was on-site at all times to meet compliance requirements.

Permanent Solution:

E3 remains enrolled in English classes to continue improving her communication abilities. The facility has also updated its scheduling procedures to verify that at least one English-proficient staff member is always present on the premises. Going forward, any staff member considered for a manager designee role will be evaluated for English proficiency to ensure full compliance.

Person Responsible:

E2 – Facility Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-806.A.8.a-b. Personnel A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;

Evidence/Findings:

Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for three of three personnel 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, 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) or Interferon Gamma Release Assay (IGRA) test is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of the personnel records revealed no record for E1. 4. A review of E2’s personnel revealed documentation of a negative T-spot blood test, however no documentation of a TB risk assessment and a TB signs/symptoms screening. Based on E2’s hire date, this documentation was required. 5. A review of E3’s personnel record revealed documentation of two negative Mantoux skin tests, however no documentation of a TB risk assessment and a TB signs/symptoms screening. Based on E3’s hire date, this documentation was required. 6. A review of the facility's policies and procedures revealed a policy titled “Tuberculosis (“TB”) Testing.” The policy stated, “The TB test/screening must be BOTH administered AND read prior to the individual being accepted as a resident or as an employee, providing services to residents, or moving into the facility. TB test/screening can be administered up to 7 days after admission.” 7. A review of the August 2025 personnel work schedule revealed E2 and E3 were scheduled for every day in August. 8. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Temporary Solution:

All employee personnel files were immediately reviewed, and the TB testing, risk assessment, and symptom screening documents were moved to the main section of each file to ensure they are clearly visible and accessible.

Permanent Solution:

To prevent this issue from recurring, the facility has organized all personnel files into a standardized format where medical and screening documentation is stored under a clearly labeled “Health & TB Records” tab. Additionally, the facility has implemented a new application that tracks and reminds management of all health screening renewals and annual requirements. Calendar alerts are also in place to ensure timely updates.

Person Responsible:

E2 – Facility Manager

Deficiency #4

Rule/Regulation Violated:

R9-10-806.C.1.a-c. Personnel C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual’s name, date of birth, and contact telephone number; b. The individual’s starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of: i. The individual’s qualifications, including skills and knowledge applicable to the individual’s job duties; ii. The individual’s education and experience applicable to the individual’s job duties; iii. The individual’s completed orientation and in-service education required by policies and procedures; iv. The individual’s license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or policies and procedures; and ix. Compliance with the requirements in A.R.S. § 36-411(A) and (C); and x. The certificate of completion, according to R9-10-126;

Evidence/Findings:

Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained for each employee as required. The deficient practice posed a risk as the required information could not be verified for E1. Findings include: 1. Upon arrival at the facility, E3 and E1 were the only employees at the facility. 2. During an interview, E3 reported E3 did not speak or understand English. E3 reported that E1 would assist with questions. 3. During an interview, E1 reported E3 was not good with English and that E1 was covering as E2 was off. 4. A review of the personnel records revealed no record for E1. 5. A review of E3’s personnel records revealed no documentation of the following: -verification that a potential employee is not on the adult protective services -caregiver certification -individual’s qualification, including skills and knowledge applicable to the individual’s job duties 6. A review of the August 2025 personnel work schedule revealed E3 was scheduled for every day in August.E1 was not listed on the work schedule. 7. During an interview, E1 reported E1 was working in the facility for the past four days. 8. In an interview, E2 stated “E1 was covering. E2 did not have time to complete E1’s personnel record and asked E1 to complete E1’s self.” 9. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Temporary Solution:

All personnel files were immediately reviewed and updated to ensure that required documentation was complete and properly maintained. Missing or misplaced records were added or reorganized to ensure each file is accurate and accessible for review.

Permanent Solution:

The facility has revised its hiring process to ensure that no employee begins work until all required documents—including APS clearance, qualifications, certifications, and employment records—are verified and filed. The personnel file format has been standardized with clearly labeled sections for ease of review and consistency. Additionally, a new tracking system and calendar reminder feature have been implemented to help the manager monitor onboarding documentation and renewals.

Person Responsible:

E2 – Facility Manager

Deficiency #5

Rule/Regulation Violated:

R9-10-810.B.2.i. Resident Rights B. A manager shall ensure that: 2. A resident is not subjected to: i. Restraint;

Evidence/Findings:

Based on observation, documentation review, record review, and interview, the manager failed to ensure that a resident was not subjected to restraints for one of seven residents sampled. The deficient practice posed a risk of injury and violated a resident’s rights. Findings include: 1. R9-10-101.202 defines “Restraint” as any physical or chemical method of restricting a patient’s freedom of movement, physical activity, or access to the patient’s own body. 2. During an environmental inspection of the facility, the Compliance Officers (COs) observed R1 lying in bed sleeping with half bedrails in the upright position along the side at the head of the bed and at the foot of the bed. The bed was placed against the wall. 3. The COs observed E1 raise and lower the bedrails similar to R1’s bedrails. The mechanism for raising and lowering the bedrail was accessible from outside the bed. E1 turned the mechanism to loosen the screw. Then E1 grabbed the bedrail with two hands to raise the bedrail. It took E1 some force to raise and lower the rail. 4. A review of the facility’s policies and procedures revealed a policy and procedure titled “Limitations on Level of Service and Use of Restraints.” The policy stated “Staff, Manager, and/or Owner shall ensure bed rails are never used in the facility.” 5. A review of R1’s service plan revealed the following: -R1 was wheelchair bound and not bed-bound -R1 was a one-person assist with walking, standing, and transfers. 6. In an interview, E2 stated, “R1 is not bed-bound and should not have the bedrails up.” 7. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Temporary Solution:

Immediately following the inspection on September 2, 2025, all bedrails were removed from the facility. Hospice was contacted to retrieve and take possession of the equipment to ensure that no bedrails remain available for use. The resident involved is no longer subject to bedrails or any form of restraint.

Permanent Solution:

The facility has reinforced its policy prohibiting the use of bedrails or any other physical restraints. All staff have been re-educated on resident rights and the facility’s zero-tolerance policy regarding restraints. A procedure has been implemented to verify that any equipment brought into the facility by hospice or families does not include bedrails or restraint devices.

Person Responsible:

E2 – Facility Manager

Deficiency #6

Rule/Regulation Violated:

R9-10-810.C.3.a-c. Resident Rights C. A resident has the following rights: 3. To receive privacy in: a. Care for personal needs; b. Correspondence, communications, and visitation; and c. Financial and personal affairs;

Evidence/Findings:

Based on observation, documentation review, and interview, the manager failed to ensure a resident has the right to receive privacy in care of personal needs, correspondence, visitation, and personal affairs. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a television in the kitchen with four different boxes on it. Three of the boxes had a different resident’s room, and the last box had a view of the medication cabinet. 2. A review of R1’s medical record revealed no documentation of consent to be monitored by a camera in R1’s private space. 3. A review of E1’s personnel record revealed a document titled “Facility Use of Camera.” The document stated, “Cameras are not located in resident bedrooms or bathrooms.” 4. A review of the facility's policies and procedures revealed no documentation on monitoring residents in their bedrooms by camera. 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Temporary Solution:

After the inspection on September 2, 2025, the kitchen television monitor was immediately reconfigured so that no resident room feeds could be viewed. The staff member responsible (E1) had switched the display without authorization and has since been retrained on privacy policies and the proper use of monitoring systems. All access to resident room cameras was removed from the kitchen display to prevent any recurrence.

Permanent Solution:

The facility maintains signed consent forms for each resident or their POA authorizing the use of non-recording baby monitors in rooms for safety purposes. These forms were already in each resident’s admission file but have now been placed in a clearly labeled section for easier verification. The facility’s policies and procedures have been updated to include a clear statement regarding the permitted use of monitors and the prohibition of displaying resident room feeds on shared screens.

Person Responsible:

E2 – Facility Manager

Deficiency #7

Rule/Regulation Violated:

R9-10-811.C.13.c. Medical Records C. A manager shall ensure that a resident’s medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and

Evidence/Findings:

Based on observation, record review, documentation review, and interview, the manager failed to ensure a resident’s medical record included an accurate name and signature of the individual administering medication for two of two residents sampled. The deficient practice posed a health and safety risk to residents if the facility did not properly document medication administration for a resident, and the Department was provided false or misleading information. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers (COs) observed E1 open the medication cabinet and take out medication. E1 crushed the medication and placed it in applesauce. E1 fed the applesauce to a resident who was sitting at the dining room table. E1 did not document the administration of the medication. 2. The COs observed the following: -E1 unlocking the computer -E1 accessing residents' records -E1 locking the computer 3. A review of the personnel records revealed no record for E1. 4. A review of R1’s electronic medical record revealed that E3 administered medication at 8:00 am on September 2, 2025. 5. During an interview, E3 reported E3 did not speak or understand English. 6. A review of the August 2025 electronic medication administration records (MARs) revealed that E3 had signed and dated the MARs for 26 of 31 days in August. 7. A review of R1’s August 2025 MAR revealed E3 signed and dated for Levetiracetam 1000mg oral tablet administered twice a day at 8:00 am on 26 of 31 days worked in August. E3 signed and dated for Levetiracetam 1000mg oral tablet administered twice a day at 8:00 pm on 28 of 31 days worked in August. 8. A review of R2’s August 2025 MAR revealed E3 signed and dated for Amlopipine 10mg oral tablet administered once a day at 8:00 am on 26 of 31 days worked in August. E3 signed and dated for Atorvastatin 40mg oral tablet administered at bedtime at 8:00 pm on 28 of 31 days worked in August. 9. The COs observed E3 unable to unlock the computer to access the MARs. E1 told E3 the password to the computer. Once the computer was unlocked, E3 was unable to find the program Synkwise. E3 looked to E1. E1 opened Synkwise for E3. Once Synkwise was open, E3 account was automatically pulled up. E3 did not know how to open a resident's record and document in the MARs. E3 looked to E1 to open the MAR. 10. In an interview, E3 stated, “E3 does not do medication administration.” E3 reported that E3 did not know how to use the computer. 11. In an interview, E1 stated, “Medication administration was previously done by the E2 and a previous caregiver.” 12. A review of E3’s personnel record revealed a document titled “Caregiver Job Description.” The Caregiver Job Description stated “documenting medications taken by the resident on the medication administration record.” The Caregiver Job Description was signed by E2 and E3 and dated on E3's hired date. 13. A review of the facility's policies and procedures revealed a policy titled “Medication Services.” The policy stated, “The caregiver will initial in the MAR for the date and time the medication was given to the resident and the medication taken.” 14. In an interview, E2 stated, “E3 is supposed to be administering medication.” 15. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Temporary Solution:

Immediately following the inspection on September 2, 2025, the facility took corrective action to address improper medication administration and documentation. E1, who administered medication without proper certification, was terminated. E3 was retrained on the Synkwise electronic medication administration system and instructed on proper procedures for documentation and the importance of maintaining password confidentiality.

Permanent Solution:

The facility reinforced its medication policy to ensure that only trained, certified, and authorized caregivers administer medications and document them in the MAR. Comprehensive retraining was provided to all caregiving staff, emphasizing proper medication handling, documentation accuracy, and adherence to state regulations. Additionally, the manager implemented a sign-in protocol for Synkwise to track medication entries by individual user credentials and prevent unauthorized access. Also, the passwords expire every 90 days and must be reset in order to ensure that they are more secure.

Person Responsible:

E2 – Facility Manager

Deficiency #8

Rule/Regulation Violated:

R9-10-818.C.4.a. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 4. Potentially hazardous food is maintained as follows: a. Foods requiring refrigeration are maintained at 41° F or below; and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that food requiring refrigeration was maintained at 41°F or below. The deficient practice posed a risk of potential foodborne illness. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed an opened bottle of Wilsey mayonnaise and an opened bottle of Sweet Baby Ray’s barbecue sauce in the pantry in the kitchen. The labels on both bottles stated “Refrigerate after opening.” 2. In an interview, E1 reported that E1 did not realize the bottles needed to be refrigerated. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Temporary Solution:

Immediately following the inspection on September 2, 2025, all improperly stored opened food items were discarded. The manager confirmed that all remaining perishable items were properly stored in the refrigerator at or below 41°F. A refrigerator thermometer was placed in the door, which is the warmest part of the refrigerator, to ensure accurate temperature readings.

Permanent Solution:

All staff have been re-educated on proper food storage and temperature control requirements. The facility implemented a food storage checklist and posted reminders in the kitchen regarding safe storage practices and thermometer placement. A photo of the thermometer in the correct location will be provided.

Person Responsible:

E2 – Facility Manager

Deficiency #9

Rule/Regulation Violated:

R9-10-820.A.11. Environmental Standards A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

Evidence/Findings:

Based on observation, interview, and documentation review, the manager failed to ensure that toxic materials were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed the laundry door with no lock. The following were found on the washer and dryer: -Glade air freshener -Lysol Disinfectant Spray -Oxi Clean -Kirkland Laundry Detergent 2. During an environmental inspection of the facility, the Compliance Officers observed Lysol Disinfecting Wipes on a shelf above the toilet. 3. During an environmental inspection of the facility, the Compliance Officers observed a bathroom cabinet in the primary bathroom unlocked. The cabinet had a lock, but it was not latched. The following were observed: -Two bottles of Lysol Disinfecting Wipes -Two bottles of Lysol Disinfectant Spray - Two cans Comet with Bleach 4. A review of the facility’s policies and procedures revealed a policy and procedure titled “Facility Grounds Safe and Free of Hazards.” The policy stated “The facility manager and/or that owner and staff will ensure that all poisonous or toxic materials (this is to include all cleaning supplies) will be stored and maintained in labeled containers in a locked area separated from food preparation and storage, dining areas, and medications.” 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Temporary Solution:

Immediately following the inspection on September 2, 2025, all toxic materials and cleaning supplies were secured in locked storage areas to ensure they were completely inaccessible to residents. The laundry room door lock was replaced with an automatic self-locking mechanism, and staff were reminded of the policy requiring that all cleaning and chemical products remain locked when not in active use.

Permanent Solution:

To further enhance safety and ensure full compliance, the facility relocated most chemical and cleaning products to a locked cabinet in the garage, which remains secured at all times. The laundry room door was upgraded with an auto-close, self-locking mechanism to prevent accidental access, and the fire extinguisher was moved out of the laundry area to allow the entire room to remain locked at all times. Clear signage has been posted in every area where chemicals are used, reminding staff that all toxic materials must be secured and properly labeled. The facility’s evacuation plan has been updated to include the new fire extinguisher location, and the updated plan has been posted throughout the home. All staff have been retrained on hazardous material storage, safety procedures, and compliance expectations.

Person Responsible:

E2 – Facility Manager

Facility Information

Inspection History

INSP-0158765

Summary:

Deficiencies Found: 9

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #9

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0082453

Summary:

INSP-0082452

Summary: