Goldwater Legacy Assisted Living

Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery, for one of three sampled staff. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed policy and procedure (P&P) titled “Fall Prevention and Recovery Training. The P&P stated: “1. The established care home will provide and deliver training for employees on Fall Prevention and Fall Recovery. 2. New employees, prior to providing services to the residents of the residential assisted living home, will need to complete 2 CEUs of Fall Prevention and Fall Recovery.” The review further revealed a series of personnel schedules which indicated E3 worked on September 15-19, 22-26, and 29-30, 2025, and October 1-2, 6-10, 13-17, and 20, 2025. 2. A review of E3’s personnel record revealed E3 was hired as an assistant caregiver on September 15, 2025. The review revealed documentation of training regarding fall prevention and fall recovery completed on October 21, 2025, more than one month after E3 began providing services at the facility. 3. In the exit interview, the Compliance Officer reviewed the findings with O1 and O1 stated, “Okay.”

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan, for one of two sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan. Findings include: 1. A review of R2's medical record revealed a service plan dated as initially developed on February 10, 2025, and updated on July 3, 2025; October 3, 2025; and January 2, 2026. The service plan indicated facility personnel were to shower R2 two times per week and as needed. The review further revealed documentation of assisted living services (ADLs) provided to R2 dated January 2026. The ADLs indicated R2 received baths on January 2, 7, 9, 14, and 16, 2026, from hospice and only once on January 15, 2026, from facility personnel. 2. In an interview, O1 reported R2 received R2’s scheduled baths from hospice and not from facility personnel. 3. In the exit interview, the Compliance Officer reviewed the findings with O1 and O1 provided no additional information.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for three of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of CDC.gov revealed a webpage titled "Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019," published by the U.S. Department of Health and Human Services. The webpage stated: "The 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include…6) annual TB education of all health care personnel." The review of the website revealed the 2005 CDC recommendations on a webpage titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The webpage stated: "The setting should document that all HCWs [Health-Care Workers]...have received initial TB training relevant to their work setting and additional occupation-specific education. The level and detail of baseline training will vary according to the responsibilities of the HCW and the risk classification of the setting." 2. A review of facility documentation revealed a policy and procedure (P&P) titled "Tuberculosis Test (TB).” The P&P stated, “Prior to providing services to the residents of the residential assisted living home and annually (once a year), all employees must undergo training and education related to recognizing the signs and symptoms of TB.” The review further revealed a series of personnel schedules which indicate the following: - E2 worked on a regular basis between January 2025 and January 2026; - E3 worked on a regular basis between September 15, 2025, and October 21, 2025; and - E4 worked on a regular basis between October 1, 2025, and the date of the inspection. 3. A review of E2’s personnel record revealed E2 was hired as an assistant manager on October 21, 2024, then was later promoted to manager. However, the review revealed no documentation of training and education related to recognizing the signs and symptoms of TB within one year before the date of the inspection. 4. In an interview regarding E2’s annual training, O1 stated, “We’ll have to get it done.” 5. A review of E3’s personnel record revealed E3 was hired as an assistant caregiver on September 15, 2025. The review revealed documentation of training and education related to recognizing the signs and symptoms of TB completed on October 21, 2025, more than one month after E3 began providing services at the facility. 6. A review of E4’s personnel records revealed E4 was hired as a caregiver on September 22, 2025. However, the review revealed no documentation of training and education related to recognizing the signs and symptoms o

Based on documentation review, record review, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers working each day, including the hours worked by each. Findings include: 1. A review of facility documentation revealed a personnel schedule dated January 2026 which indicated the following: - E2 worked from 6:00 AM to 6:00 PM on January 1-2, 5-8, 12-15, and 19-20, 2026; - E2 did not work from 6:00 PM to 6:00 AM in January 2026; - E5 worked from 6:00 AM to 6:00 PM on January 2-4 and 9-10, 2026; and - E5 worked from 6:00 PM to 6:00 AM on January 5, 2026. 2. A review of R1’s and R2’s medical records revealed documentation of assisted living services (ADLs) provided to R2 and medication administration records (MARs) for R1 and R2, each dated January 2026. The ADLs and MARs revealed documentation demonstrating the following: - E2 provided night checks at 1:00 AM, 3:00 AM, 5:00 AM, 7:00 PM, 9:00 PM, and 11:00 PM on January 15, 2026, even though E2 did not work during those times on that date; - E2 administered medication at 8:00 AM on January 16, 2026, even though E2 did not work at 8:00 AM on that date; - E5 administered medication at 8:00 AM on January 11 and 16-18, 2026, even though E5 did not work at 8:00 AM on those dates; and - E5 administered medication at 8:00 PM on January 3-4, 8-11, and 16-18, 2026, even though E5 did not work at 8:00 PM on those dates. 3. In an interview, when the Compliance Officer pointed out the fact that the ADLs and MARs did not match the personnel schedule, O1 stated, “You’re right.” O1 reported the personnel schedule was not correct. 4. In the exit interview, the Compliance Officer reviewed the findings with O1 and O1 provided no additional information.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of one sampled caregiver. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled “First Aid and CPR training.” The P&P stated: “1. On the date of hire or start date (if not already trained), each new employee or volunteer will be required to have in person CPR and First Aid training specific for adults from a CPR and First Aid training organization…2. First Aid and CPR certification must be completed via an in-person training/certification process from a third-party company.” The review further revealed a series of personnel schedules which indicated E4 worked alone on a regular basis between October 1, 2025, and the date of the inspection. 2. A review of E4’s personnel records revealed E4 was hired as a caregiver on September 22, 2025. The review revealed a printout of E4's CPR training certification from NationalCPRFoundation dated as issued on September 25, 2025. However, the review revealed no other CPR training certification. 3. A review of the NationalCPRFoundation website revealed E4's CPR training was online-only and did not include a demonstration of E4's ability to perform CPR. 4. In an interview, when the Compliance Officer asked if E4 had any CPR training certification that included a demonstration of E4's ability to perform CPR, O1 stated, “We don't have anything to give to you.” 5. In the exit interview, the Compliance Officer reviewed the findings with O1 and O1 provided no additional information.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident’s date of occupancy, and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113(A)(2)(a)(i-ii) 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…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 [and] ii. Determining if the individual has signs or symptoms of tuberculosis." 2. A review of facility documentation revealed a policy and procedure (P&P) titled “Tuberculosis Test (TB).” The P&P stated: “Residents must provide evidence of freedom from infectious tuberculosis as follows: d. A TB Baseline Risk Assessment Form must be completed and signed by a Healthcare Provider. f. All documents will be kept in the resident’s file.” 3. A review of R2’s medical record revealed a document titled “Tuberculosis (TB) Screening and Risk Assessment Form.” The document included an assessment of risks of prior exposure to infectious TB and determining if R2 had signs or symptoms of TB signed by R2’s primary care physician (PCP). However, R2’s PCP did not conduct the assessment and screening until more than seven days after R2 was admitted to the facility. 4. In the exit interview, the Compliance Officer reviewed the findings with O1 and O1 provided no additional information. Technical assistance was provided on this rule during the compliance inspection conducted on September 28, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the correct time of administration or assistance, for two of two sampled residents. Findings include: 1. A review of facility documentation revealed a personnel schedule dated January 2026 which indicated the following: - E2 worked from 6:00 AM to 6:00 PM on January 1-2, 5-8, 12-15, and 19-20, 2026; - E2 did not work from 6:00 PM to 6:00 AM in January 2026; - E5 worked from 6:00 AM to 6:00 PM on January 2-4 and 9-10, 2026; and - E5 worked from 6:00 PM to 6:00 AM on January 5, 2026. 2. A review of R1’s and R2’s medical records revealed medication administration records (MARs) dated January 2026. The MARs revealed documentation demonstrating the following: - E2 administered medication at 8:00 AM on January 16, 2026, even though E2 did not work at 8:00 AM on that date; - E2 administered medication at 8:00 PM on January 1-2, 5-8, 12-15, and 19, 2026, even though E2 did not work at 8:00 PM on those dates; - E5 administered medication at 8:00 AM on January 11 and 16-18, 2026, even though E5 did not work at 8:00 AM on those dates; and - E5 administered medication at 8:00 PM on January 3-4, 8-11, and 16-18, 2026, even though E5 did not work at 8:00 PM on those dates. 3. In an interview, when the Compliance Officer asked if E2 administered medication to R1 and R2, E2 stated, “Yes.” When the Compliance Officer asked when E2 administered R1’s and R2’s evening medications, E2 stated, “Around 6:00 PM right before we leave.” E2 reported E2 signed off on the MARs as having administered the medications at 8:00 PM even though E2 administered the medications at 6:00 PM. 4. In the exit interview, the Compliance Officer reviewed the findings with O1 and O1 stated, “Right, okay.”