YUCCA ASSISTED LIVING LLC

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. A review of facility documentation revealed a document labeled "Fall prevention and recovery training programs." The program stated "1. All employees will have an initial training on fall prevention and recovery. Training shall be included in the orientation for new hires...3. After initial training, all employees will be required to attend continuing competency training on fall prevention and recovery at least every 12 months. Completion of the training shall be documented and included in the employee files."

2. A review of E1's personnel record revealed documented fall prevention and recovery training dated May 2022. However, E1's personnel record did not include a current annual training for fall prevention and recovery as required per the documented program.

3. In an interview, E1 acknowledged the facility's fall prevention and fall recovery program was not administered according to the documented program requirements.

This is a repeat citation from the previous on-site compliance inspection conducted on December 14, 2021.

Based on documentation review, record review, and interview, the manager failed to ensure cardiopulmonary resuscitation (CPR) training included a demonstration of the employee's ability to perform CPR, for one of two sampled employees.

Findings include:

1. A review of facility documentation revealed a daily staffing schedule for July 2023. The July 2023 schedule indicated E2 was scheduled to work the "full day" shift from 6:00 AM to 6:00 PM and "Night" shift from 6:00 PM to 6:00 AM every Monday through Saturday in July 2023.

2. A review of E2's personnel record revealed documentation of first aid and CPR training. However, the training was taken through an online course, and did not include a demonstration of E2's ability to perform CPR.

3. In an interview, E2 reported E2's CPR and first aid training was completed online.

4. In an interview, E1 acknowledged the manager failed to ensure E2's CPR training included a demonstration of E2's ability to perform CPR.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(C)(1), for one of two employees sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411(C)(1) states: "C. Owners shall make documented, good faith efforts to: 1. 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. A review of E2's personnel record revealed E2 had a valid fingerprint clearance card. However, documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) was not available for review.

3. In an interview, E1 acknowledged documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) for E2 was unavailable for review.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration.

Findings include:

1. A review of R2's medical record revealed a current service plan for personal care services. The service plan revealed R2 received medication administration.

2. The Compliance Officer observed a bottle of "Trazadone 50 mg (milligrams) tablets", a bottle of "Escitalopram 10 mg", and a bottle of "Donepezil 10 mg" in a medication box belonging to R2.

3. A review of R2's medical record revealed medication orders for "Trazadone 50 mg tablets" and "Escitalopram 10 mg" were unavailable for review. R2's medical record contained a medication order for "Donepezil 10 mg, 1 tablet by mouth HS."

4. A review of R2's medical record revealed a medication administration record (MAR) dated July 2023. R2's July 2023 MAR revealed "Trazadone 50 mg" was documented as administered on July 1-26, 2023, at 6:00 PM, "Escitalopram 10 mg" was documented as administered on July 1-25, 2023 at 6:00 PM, and "Donepezil 10 mg, 2 tablets" was documented as administered on July 1-25, 2023, at 6:00 PM.

5. In an interview, E1 reported the medication orders for "Trazadone 50 mg" and "Escitalopram 10 mg" were not available for review. E1 acknowledged "Donepezil 10 mg" was not administered to R2 in compliance with the medication order.