Surprise Comfort Home Care.

“Based on record review, and interview, the manager failed to provide to the emergency responders a written document that included all information required in A.R.S. § 36-420.04, for one of two applicable residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident.   Findings include: 1. A review of R1's medical record revealed an incident report dated Febuary 24, 2026, that identified R1 required 911 medical services. However, there was no documentation of all required information in A.R.S. § 36-420.04, including basic information about the resident's physical and mental conditions, as well as dates of recent episodes. 2. In an exit interview, the findings were reviewed with E3, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by an assisted living facility, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse. Findings include: 1. Record review revealed R2's pre-admission determination, which included whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a medical practitioner. However, this was not completed within 90 days before R2 was admitted to the facility. 2. In an exit interview, findings were discussed with E3 and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a service plan was signed and dated by the resident or resident's representative when the service plan was initially developed or when updated, for one of three sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated January 16, 2026, for directed care services. However, the service plan had not been signed and dated by the resident or resident's representative. 2. In an exit interview with E1, the findings were reviewed, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that one of two sampled residents' service plan was developed with assistance and reviewed by the resident or resident’s representative and the manager.   1. A review of R2’s medical record revealed a service plan dated February 26, 2025, did not reflect that R2’s service plan was developed or reviewed by R2 or R2’s representative or the manager.   2. In an interview, E3 reviewed and acknowledged that R2’s service plan did not reflect R2’s service plan was developed with assistance and reviewed by R2 or R2’s representative or the manager.”

“Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer opioids identified the resident's need for an opioid before administering the opioid and monitored the resident's response to the opioid for residents who did not have an active malignancy or an end-of-life condition.  Findings include:  1. Review of the facility’s policies and procedures revealed a policy titled, “ Part II- Doctor Orders, Provisions, and Handling of Narcotics, Opioids, Schedule 2 Medications, Controlled Substances,” Which stated, “9. Documentation in the NAR will include at minimum: a. Reason for the need of administration/ b. Evaluation of the resident need for this administration/ c. The amount of medication given and number of medication left in the container./ d. How effective the dose of the medication administered at half an hour, two hours and four hours after administration,”  2. Review of R2’s medical record revealed a medication order dated March 12, 2025 for “Tramadol 50 mg Take .5 (half) tab by mouth every 6 hours as needed for pain.” 3. Review of R2's medical record revealed a medication administration record (MAR) dated April 2025. The April 2025 MAR revealed, “Tramadol 50 MG TAB take ½ tab PO Q 8 hr.” The April 2025 MAR revealed Tramadol 50 MG was administered once a day, April 1, 2025 to present. 4. Review of R2’s Narcotic Administration Record (NAR) for April 2025 revealed documentation of the pain level, doses given, and doses left (which was marked as Pain). However, there was no documentation for monitoring the resident response as “30-40 min after administration”, “2 hours after administration”, and “4 hours after administration” per the policy.  5. In an interview, E3 reported R2 did not have an active malignancy or an end-of-life condition.  6. In an interview, E3 acknowledged R2’s response to the opioid was not documented per the policy.”

“Based on documentation review, observation, and interview, the governing authority failed to notify the Department immediately when there was a change in the manager. Findings include: 1. A review of Department documentation revealed E3 was listed as the manager on record. 2. During an environmental inspection of the facility, the Compliance Officer observed E1's manager certificate posted in the foyer. The Compliance Officer observed E3's manager certificate was not posted. In the office, the Compliance Officer observed two "DELEGATION OF MANAGER"S AUTHORITY" forms dated May 1, 2024, listing E1 as the manager. 3. A review of R1's medical record revealed a residency agreement signed by E1 in the capacity of "Manager." 4. In a telephonic interview, E1 stated, "I am the manager." E1 reported E3 was the manager before E1. E1 reported E1 became the manager in the middle of the year. 5. A review of Department documentation revealed no notification of E1's appointment as manager. Technical assistance was provided on this rule during the on-site abbreviated initial follow-up inspection conducted on February 27, 2024.”

“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 a residency agreement. However, the residency agreement did not include R1's date of occupancy or expected date of occupancy. 2. In an interview, E1 reported E1 sent R1's residency agreement for signature and was going to update the agreement with R1's date of occupancy once R1 moved in, but never did. Technical assistance was provided on this rule during the on-site abbreviated initial follow-up inspection conducted on February 27, 2024.”

“Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort 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 egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officer observed two doors leading from the side and back of the facility to an outdoor covered patio. The Compliance Officer observed the doors did not have controls installed but did have alerts installed. However, the alerts were turned off and did not sound when the Compliance Officer opened the doors. The Compliance Officer observed the front door had a control and an alert installed. However, the control was not in use at the time and the alert did not sound when the Compliance Officer opened the door. 3. In an interview, speaking of the side door, E2 stated, "No one uses it." Speaking of the back door, E2 stated, "Sometimes [the residents] smoking going out in the night." E2 stated, "I turned it off because last time it driving us crazy."”

“Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility 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 the physical health and safety of residents with access to the medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed an unlocked refrigerator in the kitchen with a variety of food and medications inside, including "BROM/PSE/DM SYP ACE," "Children's Tylenol," "Equate DAYTIME Cold & Flu," "Kroger Stomach Relief Bismuth Subsalicylate," "Lorazapam Intensol," and "MAX Tussin DM Cough Chest Congestion." 2. In an interview, when the Compliance Officer brought the deficiency to E2's attention, E2 stated, "I know." E2 acknowledged medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. 3. The Compliance Officer observed an unlocked and open door leading into a caregiver room some 20 feet away from several residents sitting in the living room. Before stepping into the room, the Compliance Officer observed something that looked like medication inside the room. 4. In an interview, E2 promptly reported the Compliance Officer was not allowed to go into the room. E2 reported the room contained E2's private and personal items. E2 stated, "I have blood pressure medication I'm hiding" and "I have a blood sugar medication I'm hiding." 5. In a telephonic interview held in the office, E2 reported to E1 that E2 had medication inside E2's room. 6. After the telephonic interview, E2 returned to E2's room, entered, and showed the Compliance Officer several medications stored in an unlocked drawer in the still unlocked and open room.”

“Based on observation, record review, and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed R1 in a wheelchair with a seatbelt that secured R1 to the chair. 2. Review of R1's medical record revealed a document titled "Resident's Services (90 day assessment)" signed and dated by E1 February 23, 2024. This document stated "Yes - Resident requires restraints - When in wheel chair (seat belt) when toileting (seat belt) for safety". 3. In an interview, E2 reported R1 could not remove the seatbelt. E2 reported the seatbelt was used to prevent R1 from falling out of the wheelchair. 4. In a telephone interview, E1 reported the seatbelt was used at R1's family's request and acknowledged the seatbelt secured R1 to the wheelchair and could cause R1 to suffer physical injury.”