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.”