Caring Hands Comfort Assisted Living Home LLC.

“Based on documentation review and interview, the manager failed to document suspected abuse, neglect, or exploitation, Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days; The dates, times, and description of the suspected abuse, neglect, or exploitation; A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition; the names of witnesses to the suspected abuse, neglect, or exploitation; and the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: A review of facility documentation revealed an incident report regarding R1, dated January 24, 2025. The incident report stated, "I [E1] came to work on Friday Morning to [R1] complaining about Graveyard worker [E5] not letting [R1] go in the refrigerator for cheese, [E5] asked [R1] to ask for what [R1] needs. This incident report included an investigation of the complaint and was concluded within one working day, resulting in the termination of [E5]. A review of facility documentation revealed an incident report regarding R1, dated January 30, 2025 at 4:05 PM. The incident report stated, "[R1] asked [E1] for [R1's] pain medication at 4 pm, but when [R1] asked for it [R1] said, 'I want to see the label to see how much milligrams it is,' so [E1] told [R1] 'remember baby, your on a lower dose,' and [R1] was so upset [R1] said [R1] would call Adult Protective Services. The incident included a timely investigation of the allegation and the report concluded, "The resident's medication schedule will be reviewed with the healthcare team to ensure clarity and consistency. Staff Training. Caregivers will receive additional training on managing resident's agitation and effective de-escalation strategies. A review of facility documentation revealed no other incidents or investigations conducted during this time period. In an interview, the Compliance Officer asked E1 if E1 was aware of an allegation of verbal abuse, opioid diversion, and of a staff member working without fingerprint clearance. E1 reported the facility was aware of this allegation and stated an investigator from Adult Protective Services (APS) had been at the facility on the same day as the previous incident with R1, on January 30th, 2025, and had advised them of the allegations. E1 reported E3 does have a fingerprint clearance card, the opioids were accounted for, and when APS spoke with R1, they decided R1 was upset with E5, from the January 24, 2025 incident. E1 reported this was about three days after E5 had been terminated and the report mentioned the other two employees but not E5, so they thought it was probably retaliatory and not credible. During the onsite inspection, the Compliance Officer requested documentation of the investigation conducted within five days after the facility became aware of the allegations on January 30, 2025, however, documentation of this investigation was not available for review. In an interview, E1 reported the APS visit and allegations had been documented, but E1 reported being unable to locate the documentation during the on-site inspection. E1 acknowledged documentation of the facility's investigation into the allegations of verbal abuse, opioid diversion, and a staff member working without a fingerprint clearance card had not been provided for review. This is a repeat deficiency from the on-site complaint inspection conducted on May 28, 2024”

“Based on record review and interview, the manager failed to ensure that a resident's written service plan was signed by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated November 14, 2024. However, the service plan did not include a signature from R1 or R1's representative, the manager, or the nurse who reviewed the service plan. 2. In an interview, E1 acknowledged R1's service plan were not signed by the resident or resident's representative, the manager, or the nurse who reviewed the service plan.”

“Based on observation and interview, the manager failed to ensure that foods requiring refrigeration were maintained at 41° F or below. Findings include:  1. During an environmental tour of the facility, the Compliance Officer observed the following food open and stored in the facility’s unrefrigerated pantry:  Grape Jelly;  Sweet and Sour Sauce; and Ketchup.  2. During an environmental tour of the facility, the Compliance Officer observed a refrigerator in the kitchen contained food items requiring refrigeration. The refrigerator contained three thermometers, two of which read 50 degrees and one of which read 55 degrees. E4 immediately changed the refrigerator setting from 37 degrees to 33 degrees and The Compliance Officer checked the refrigerator again approximately an hour later, however, the temperature readings had not changed. 3. In an interview, E1 acknowledged foods requiring refrigeration had not been maintained at 41° F or below.”

“Based on document review and interview, after the manager had a reasonable basis, according to A.R.S. \'a7 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to document the suspected abuse, neglect, or exploitation, and any action taken according to subsection (J)(1), failed to initiate an investigation of the suspected abuse, neglect, or exploitation and within five day after the report required in subsection (J)(2), document the dates, times, and description of the suspected abuse, neglect, or exploitation, a description of any injury to the resident related to the suspected abuse or neglect and any change to the resident's physical, cognitive, functional, or emotional condition, the names of witnesses to the suspected abuse, neglect, or exploitation, and the actions taken by the manager to prevent the suspected abuse, neglect, or exploitation from occurring in the future. Findings include: 1. A review of the facility's policies and procedures, last reviewed February 15, 2024, revealed a policy titled "Reporting Abuse, Neglect & Exploitation." This policy stated, "If the facility manager has a reasonable basis to believe abuse, neglect, or exploitation of a resident is alleged or suspected to have occurred on the premises or while a resident is receiving services from this facility's manager, caregiver, or assistant caregiver: Take immediate action to stop the alleged or suspected abuse, neglect or exploitation; Immediately report the alleged or suspected abuse, neglect, or exploitation of the resident they must call Law Enforcement or Adult Protective Services; Document the alleged or suspected abuse, neglect, or exploitation, the action taken and to whom the report was made to. This documentation must be maintained for 12 months after the date of the report. Investigate the alleged or suspected abuse, neglect, or exploitation and develop a written report of the investigation within five working days after the report was made to Law Enforcement or Adult Protective Services, that includes: Dates, times, and description of the alleged or suspected abuse, neglect, or exploitation; A description of any injury to the resident and any change to the resident's physical cognitive, function, or emotional condition; The names of witnesses to the alleged or suspected abuse, neglect, or exploitation; and The actions taken by the manager to prevent the alleged or suspected abuse, neglect, or exploitation from occurring in the future." 2. A review of R1's medical record revealed a document titled, "Activities of Daily Living Record," (ADL) dated May 2024. The ADL included a section for progress notes, which stated: - "Resident c/o Adult Protective Service @ 2 PM" (undated); - "Resident think APS is going to help [R1] to get VA services and to help [R1] moving out; - "5/20/24 Resident very rude to me since [R1] made a report to APS, [R1] wants to call APS every 2 days for everything, [E1]"; - "5/20/24 Resident c/o pain catheter its fine. I check. Nothing wrong but I call [home health agency] I grab the folder, I told [R1] I ' m going to call them. The [Home Health Agency] Discharge [R1], [R1's] saying I'm steal the folder from [R1]."; - "5/24 Resident c/o Catheter need to be change... I call [R1's primary care physician, who] said [they] already send the new order for home health. We waiting for home health communicate to us"; and - "5/23 Resident c/o pain catheter, [R1] was very mean to me, screaming and yelling. [R1] said I 'm not doing anything. I contact [R1's primary care physician[ re: that situation. I contact POA re: [R1's] behavior, [E1]." 3. During the on-site inspection on May 28, 2024, the Compliance Officer requested to review the initial documentation of the alleged abuse, neglect, or exploitation regarding R1 and requested to review the documentation of the investigation of the alleged abuse, neglect or exploitation completed within five days after the initial report. However, the requested documentation was not provided for review. 4. In an interview, E1 reported APS had visited twice in the past week regarding R1's allegations. E1 reported the second visit from APS was a meeting with R1's responsible party and the owner to discuss how to address R1's concerns. E1 acknowledged documentation of the alleged abuse, neglect, or exploitation was not provided for review.”

“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 which allowed a resident to be 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. During an environmental inspection of the facility, the Compliance Officer observed an exit door in the south hallway had a door alarm, however, however, the alarm had been switched off.. 3. In an interview, E1 acknowledged there was a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility which did not control or alert employees of the egress of a resident from the facility. This is a repeat deficiency from the on-site compliance inspection conducted on June 8, 2023.”