Inspection Reports for Southwest Comfort Care
8608 E Roanoke Ave, Scottsdale, AZ 85257, United States, AZ, 85257
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Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 15
Oct 15, 2024
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-05 to 2024-10 with deficiency history
Findings
Across three inspections conducted between May 2023 and October 2024, multiple deficiencies were cited including failures in policy implementation, personnel record maintenance, medication administration compliance, resident service provision, and facility safety measures. Several deficiencies were repeated or uncorrected from prior inspections.
Complaint Details
The page includes complaint investigations conducted on 2024-02-08 and 2024-10-15 involving multiple deficiencies related to resident safety, medication administration, personnel records, and policy compliance.
Deficiencies (15)
| Description |
|---|
| C. A manager shall ensure that policies and procedures are: 1.m. Cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide; |
| 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. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C); |
| C. A manager shall not accept or retain an individual if: 2. The primary condition for which the individual needs assisted living services is a behavioral health issue; |
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: a. Provides a resident with the assisted living services in the resident's service plan; |
| F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility; |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident's medical record. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program. |
| E. A manager shall ensure that, unless otherwise stated: 1. Documentation required by this Article is provided to the Department within two hours after a Department request; |
| A. A manager shall ensure that: 1. A caregiver: b. Provides documentation of: i. Completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers; |
| C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: c. Documentation of: i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties; |
| C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: c. Documentation of: iii. The individual's completed orientation and in-service education required by policies and procedures; |
| B. A manager shall 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 and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 calendar days after the resident's date of acceptance; |
| C. A manager shall ensure that a resident's medical record contains: 1. Resident information that includes: a. The resident's name, and b. The resident's date of birth; 2. The names, addresses, and telephone numbers of: a. The resident's primary care provider; b. Other persons, such as a home health agency or hospice service agency, involved in the care of the resident; and c. An individual to be contacted in the event of emergency, significant change in the resident's condition, or termination of residency; 3. If applicable, the name and contact information of the resident's representative and: a. The document signed by the resident consenting for the resident ' s representative to act on the resident's behalf; or b. If the resident's representative: i. Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36-3282, a copy of the health care power of attorney or mental health care power of attorney; or ii. Is a legal guardian, a copy of the court order establishing guardianship; 4. The date of acceptance and, if applicable, date of termination of residency; 5. Documentation of the resident's needs required in Arizona Administrative Code (A.A.C.) R9-10-807(B); 6. Documentation of general consent and informed consent, if applicable; 7. Except as allowed in R9-10-808(B)(2), documentation of freedom from infectious tuberculosis as required in R9-10-807(A); 8. A copy of resident's health care directive, if applicable; 9. The resident's signed residency agreement and any amendments; 10. Resident's service plan and updates; 11. Documentation of assisted living services provided to the resident; 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication; 13. Documentation of medication administered to the resident re |
Report Facts
Inspections on page: 3
Total deficiencies: 23
Complaint inspections: 2
Total capacity: 10
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