Young Family Care Homes and Investments, LLC

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Fall Prevention." However, the policy did not indicate a training program had been developed and administered to facility staff, nor did the policy address initial training or continued competency. 2. A review of E1's and E3's personnel records revealed no documentation of fall prevention and fall recovery training. 3. In an interview, E1 acknowledged E1 and E3 did not have documentation of fall prevention and fall recovery training. This is a repeat deficiency from the on-site inspection conducted May 12, 2022.

Based on observation, documentation review, and interview, the manager failed to ensure at least one qualified caregiver who was at least 21 years old had been designated in writing and was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as E2 was not designated, in writing, to be present on the premises and accountable when the manager was not present on the premises. Findings include: 1. The Compliance Officer arrived at the facility and was greeted by E2. The Compliance Officer observed E2 working alone at the facility. E2 called E1 and E1 arrived approximately 30 minutes later. 2. At one point during the inspection, E1 left the facility to pick up a computer from E1's residence. While E1 was away, the Compliance Officer requested resident medications to review. E2 reported E2 did not have a key to the medication closet and was unable to provide the medications for review. 3. During a tour of the facility, the Compliance Officer observed a posting in the foyer titled, "Delegation of Manager's Authority." The posting stated, "When the Assisted Living Facility Manager is not physically present at the facility the following trained caregiver is empowered to act on the Manager's behalf as the Manager's Designee in directing and supervising the operation of this Assisted Living Facility and providing care to the residents. A manager's designee is physically present at the facility and in charge of the assisted living facility operations. This form certifies that the following named caregiver has received the necessary training and orientation to the Facility s Policies and Procedures, Guidelines and Resident Service Plans, has access to residents records and knowledge of how to contact Resident's Representative, families and physicians in case of illness or emergencies. It also certifies that the caregiver is at least 21 years of age and can read, write, speak and understand English. The following named caregiver has agreed to accept this responsibility as evidenced by signing this form." However, E2 was not listed on the posting as a manager's designee. 4. In an interview, E1 acknowledged E2 had not been designated in writing to be present on the premises and accountable for the facility when the manager was not present on the premises. E1 reported E1 would update the posting to include E2 and ensure E2 received keys to the medication closet.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C), for one of three employees sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence to show E2 was fit to work at the assisted living facility. Findings include: 1. A.R.S. \'a7 36-411(C) states: "1. Owners shall make documented, good faith efforts to: Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card." 2. A review of E2's personnel record revealed no documentation of evidence to indicate a good faith effort to contact previous employers was made to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 3. A review of E2's personnel record revealed E2 had a valid fingerprint clearance card. However, there was no documentation of evidence to indicate good faith efforts were made to verify the current status of a person's fingerprint clearance card. 4. In an interview, E1 acknowledged E2's personnel record did not include the documentation required in A.R.S. \'a7 36-411(C).

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 that was dated within 90 days before the individual was accepted by an assisted living facility, and, if the individual was requesting or was expecting to receive supervisory care services, personal care services, or directed care services, included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician's assistant, for two of three residents sampled. The deficient practice posed a risk if a resident was not assessed and determined to be within the scope of an assisted living facility prior to receiving services. Findings include: 1. A review of R1's and R2's medical records revealed no documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to indicate whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints was available for review. 2. In an interview, E1 acknowledged R1's and R2's medical records did not contain documentation that was dated within 90 days before the individual was accepted by the assisted living facility and was signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant. E1 reported E1 was not aware of this requirement.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. The deficient practice posed a risk to the health and safety of residents if medications were not administered as ordered. Findings include: 1. A review of R1's medical record revealed a medication administration record (MAR) dated August 2023. The MAR indicated R1 received medication administration of the following scheduled medications: -Gabapentin 600 milligrams (mg), one tablet 4 times daily; -Tylenol 650 mg, one tablet every 4-6 hours; -Metformin 850 mg, one tablet twice daily; -Ibuprofen 400 mg, one tablet at lunch and bedtime; -Atorvastatin 80 mg, one tablet at bedtime; and -Mirtazapine 30 mg, one tablet at bedtime. 2. A review of R2's medical record revealed a MAR dated August 2023. The MAR indicated R2 received medication administration of the following scheduled medications: -Alendronate Sodium 35 mg, one tablet every Wednesday; -Loratadine 10 mg, one tablet daily; -Ezetimibe 10 mg, one tablet every afternoon; -Fluoxetine 40 mg, one tablet every morning; -Guanfacine 1 mg, one tablet daily; -Lacosamide 200 mg, one tablet twice daily; -Topiramate 200 mg, one tablet twice daily; -Atorvastatin 40 mg, one tablet at bedtime; -Doxepin 75 mg, one tablet at bedtime; -Fycompa 10 mg, one tablet at bedtime; -Gabapentin 300 mg, 2 capsules at bedtime; -Mirtazapine 7.5 mg, one tablet at bedtime; -Risperidone 3 mg, one tablet at bedtime; -Trazadone 100 mg, take four tablets at bedtime; and -Diclofenac 75 mg, one tablet Monday, Wednesday, and Friday. 3. A review of R1's and R2's medical records revealed no signed medication orders for the aforementioned medications. 4. E1 acknowledged the medications administered to R1 and R2 were not administered in compliance with medication orders as no orders were available for review. E1 reported E1 would follow up with the doctors to obtain signed orders. This is a repeat deficiency from the on-site inspection conducted May 12, 2022.

Based on record review, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R2's medical record revealed a service plan dated March 9, 2023. The service plan revealed R2 received medication administration. 2. A review of R2's medication administration record (MAR) revealed Trazadone 100 mg, four tablets at bedtime was listed on the MAR. However, the date slots following were empty, indicating R2 was not receiving Trazadone 100 mg. 3. A review of R2's medications revealed a medication bottle containing Trazadone 100 mg with instructions to take 4 tablets by mouth at bedtime. 4. In an interview, E1 reported a medication order was not available for review. E1 reported R2 received Trazadone 100 mg at bedtime as prescribed on the bottle. However, the medication was not being documented as administered. 5. In an interview, E1 acknowledged a medication administered to R2 was not documented in R2's medical record as required.