Inspection Reports for
Comfort Assisted Living Home

36-420.04.C — The manager failed to maintain standardized emergency responder forms for all three sampled residents, as required by statute.

R9-10-113 — The manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis before beginning services, posing a potential TB exposure risk.

R9-10-115 — The manager failed to maintain a complete personnel record for one employee, providing false information to the Department.

R9-10-808 — The manager failed to ensure residents provided evidence of freedom from infectious tuberculosis before or within seven days after occupancy, posing a potential TB exposure risk.

The manager failed to ensure a resident's medical record contained required service plan updates, missing the April 2024 update for one resident.

The manager failed to document notification of the availability of influenza and pneumonia vaccinations for one resident on a yearly basis, posing a potential illness risk.

The manager failed to ensure a door alarm provided access to the outside that controlled or alerted employees of resident egress; the alarm was non-functional.

The manager failed to ensure a medication administered to a resident was accurately documented; the medication was not physically present despite documentation indicating administration.

The manager failed to implement policies and procedures for discarding expired medication; expired medication was found in storage and not properly disposed.

The manager failed to conduct and document disaster drills on each shift at least once every three months, risking employee preparedness.

The manager failed to ensure a resident received orientation to facility exits and evacuation routes within 24 hours after acceptance.

R9-10-808 — The manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis as required, posing a TB exposure risk to residents.

The manager failed to ensure a resident submitted documentation signed by a medical practitioner or registered nurse stating whether the resident required continuous medical services, nursing services, or restraints, posing a risk if the facility was unable to meet the resident's needs.

R9-10-814 — The manager failed to ensure the facility did not accept a resident confined to a bed or chair without a written medical determination that the resident's needs could be met by the facility, posing a risk if needs were unmet.

The manager failed to ensure there was a means of exiting the facility for residents without keys or special knowledge that provided access to an outside area and alerted employees of egress, posing a risk if the facility was unaware of a resident's whereabouts.

The manager failed to ensure a medication was administered in compliance with the medication order, risking a change in the resident's condition due to improper medication administration.

The manager failed to ensure medication administration was documented in the resident's medical record, risking inaccurate verification of medication administration.

The manager failed to ensure medications were stored in a separate locked area; the medication cabinet was unlocked with a broken lock, posing a risk of resident access to medications.

R9-10-113 — The health care institution failed to provide annual training and education on recognizing tuberculosis signs and symptoms to employees, posing a risk due to lack of TB surveillance instruction.

R9-10-113 — The health care institution failed to annually assess the risk of exposure to infectious tuberculosis, posing a TB exposure risk to residents and staff.