Almost Family Assisted Living, LLC

Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution developed a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "CEU Topic Fall prevention and Fall Recovery." However, the policy did not include documentation of a required frequency for continued competency training regarding fall prevention and fall recovery. 2. In an exit interview, the findings were reviewed with E1, and no additional information was required. Technical assistance was provided regarding this rule during the complaint investigation conducted on January 13, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R1's medical record revealed documentation of R1's evidence of freedom from infectious TB, however, this documentation was not completed within seven days of R1's admission into the facility. Based on R1's date of admission, this documentation was required. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that tableware, utensils, equipment, and food-contact surfaces were clean. Findings Include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed that tableware and food-contact surfaces were left with residue on them. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented that included for a resident who required behavioral care: the psychosocial interactions or behaviors for which the resident required assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors, for one of two residents sampled. Findings include: 1. A review of R2’s medical record revealed a service plan, dated April 1, 2025, that indicated R1 required behavioral care. However, the service plan did not include the psychosocial interactions or behaviors for which the resident required assistance, psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors. 2. In an interview, E1 reported E1 was unaware of the requirements for residents receiving behavioral care. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was established, documented, and implemented, which included for a resident receiving behavioral care: review by a medical practitioner or behavioral health practitioner, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated April 1, 2025, and indicated R2 required behavioral care. However, the service plan did not include review by a medical practitioner or behavioral health practitioner. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected, sensitive resident health information being disclosed without the resident’s consent or knowledge. Findings Include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed an unlocked laptop on the table with resident and medication information open and accessible to all individuals. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure there was 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, that provided access to an outside area, and monitored 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. The facility was licensed at the directed care level. 2. During an environmental inspection of the facility with E2, the Compliance Officers observed that the doors leading to the backyard were equipped with an alarm to alert employees of egress; however, the alarm on the back door was not functioning during the inspection. 3. The Compliance Officers also observed ambulatory residents exiting the facility through the back door without additional monitoring. 4. In an exit interview. The findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that medication 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 residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed the following medications stored in the facility's unlocked refrigerator: Lorazepam Oral Syringe 2 milligrams/milliliters Lorazepam Oral Syringe 1 milliliter Triamcinolone Acetonide Cream 2. The Compliance Officers observed eleven prefilled medication organizers stored in an unlocked cabinet located within the facility's kitchen. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on interview and record review, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver documented the date and time of the accident, emergency, or injury, a description of the accident, emergency, or injury, the names of individuals who observed the accident, emergency, or injury, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future, for one of two residents sampled. The deficient practice posed a health and safety risk. Findings include: 1. In an interview, E1 reported R2 was transported to the hospital following a fall on September 23, 2025. 2. While on-site for the compliance inspection, the Compliance Officers requested all incident report documentation for R2; however, documentation of the aforementioned incident on September 23, 2025, was not available for review. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. This is a repeat deficiency from the complaint inspection conducted on December 16, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were cleaned and disinfected according to policies and procedures to prevent, minimize, and control illness or infection. The deficient practice posed a risk as the facility had not implemented its established policy and procedure to reinforce and clarify standards expected of employees. Findings Include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed visible waste residue on the residents' toilet and unclean flooring in the residents' bedrooms. 2. A review of the facility's policies and procedures, reviewed and signed by E1, titled “Security and Safety,” stated “Facility premises and equipment used must be in working order, used and cleaned according to the manufacturer’s recommendations and disinfected as needed to prevent illness or infection.” 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that the premises was free from conditions or situations that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to physical health and safety of residents. Findings Include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed razors inside the mirror cabinet in the bathroom accessible to all individuals who were ambulatory. 2. The Compliance Officers observed a blind resident in the backyard independently. A garden hose in the area was observed strewn across the walkway, not properly secured or rolled up. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to physical health and safety of residents. Findings Include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed the following bottles of toxic materials stored under the sink in an unlocked cabinet: Dawn Ultra Dawn Dish Soap Glass Cleaner 2. A review of the facility’s policies and procedures, reviewed and signed by E1, titled "Security and Safety,” stated “Poisonous or toxic materials stored by the facility are maintained in labeled containers in a locked area separated from food preparation and storage, dining areas and medications and inaccessible to residents.” 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that at least one bathroom accessible from the common area contained paper towels in a dispenser or a mechanical air hand dryer. Findings Include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed no paper towels in a dispenser in both common area bathrooms. 2. The Compliance Officers observed residents walking to those restrooms and using them. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training, for three of four personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Fall Prevention and Fall Recovery Training Program." The policy stated, "Training Program Development: a. The assisted living facility shall develop and administer a comprehensive training program for all staff members concerning fall prevention and fall recovery. b. The training program shall encompass initial training for newly hired staff and continued competency training for existing staff." 2. A review of the facility's in-service training documents revealed an inservice on fall prevention and fall recovery was administered on December 10, 2023. 3. A review of E2's personnel record did not include documentation of fall prevention and fall recovery training. Based on E2's date of hire, an initial training was required. 4. A review of E3's personnel record did not include documentation of fall prevention and fall recovery training. Based on E3's date of hire, an initial training was required. 5. A review of E4's personnel record did not include documentation of fall prevention and fall recovery training. Based on E4's date of hire, an initial training was required. 6. In an interview, E1 acknowledged that the facility failed to administer a training program for all staff regarding fall prevention and fall recovery that included initial training.

Based on observation, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. While on-site for the complaint inspection, the Compliance Officers observed E3 interacting with residents while E1 was in another room of the home. 2. A review of E3's personnel record revealed E3 was hired as an assistant caregiver. 3. In an interview E1 acknowledged that E3 interacted with residents without the supervision of a manager or caregiver.

Based on record review and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services a caregiver immediately notified the resident's emergency contact, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed documentation of an incident on November 22, 2024, at 12:11 PM, which indicated R2 needed medical services. 2. A review of the incident report from November 22, 2024, revealed documentation of R2's emergency contact's name and contact information. However, no documentation indicating R2's emergency contact was immediately contacted was available. 3. In an interview, E2 acknowledged following an accident, emergency, or injury that resulted in R2 needing medical services, a caregiver did not immediately notify the resident's emergency contact.

Based on record review and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services a caregiver documented the named of individuals who observed the accident, emergency, or injury, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed documentation of an incident on November 20, 2024, at 9:41 AM which indicated R1 needed medical services. 2. A review of the incident report from November 20, 2024, did not include the names of the individuals who observed the accident, emergency, or injury. 3. A review of R2's medical record revealed documentation of an incident on November 22, 2024, at 12:11 PM, which indicated R2 needed medical services. 4. A review of the incident report from November 22, 2024, did not include the names of the individuals who observed the accident, emergency, or injury. 5. In an interview, E2 acknowledged following an accident, emergency, or injury that resulted in R1 and R2 needing medical services, a caregiver did not document the names of individuals who observed the accident, emergency, or injury.