Legacy Adult Care Home LLC

Based on documentation review, record review, and interview, the health care institution failed to ensure a training program was administered for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of three personnel sampled. Findings include: 1. A review of E2’s personnel record revealed no evidence of documentation E2 had received initial training in fall prevention and fall recovery. 2. A review of staffing schedules revealed evidence of documentation indicating E2 worked numerous shifts during February 2025. 3. In an interview, E1 acknowledged E2 had not completed initial fall prevention and fall recovery training as required.

Based on record review and interview, the manager failed to ensure a caregiver's or assistant caregiver’s skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services for three of three certified caregivers. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of facility staff schedules revealed E1, E2, and E3 worked numerous shifts each in February, 2025. 2. A review of E1’s, E2’s, and E3's personnel records revealed evidence of documentation of verification of skills and knowledge was unavailable for review. 3. In an interview, E1 agreed documentation of verification of E1’s, E2’s, and E3's skills and knowledge was unavailable for review.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included evidence of documentation outlined in R9-10-806(C)(1)(a-c) as required for one of three personnel sampled. The deficient practice posed a risk as required information could not be verified for E2. Findings include: 1. A review of E2’s personnel record revealed evidence of documentation of the following items was unavailable for review: -starting date of employment and ending date; -qualifications, including applicable skills and knowledge; -orientation; - evidence of freedom from infectious tuberculosis (TB); and -good faith efforts to contact previous employers, per A.R.S. § 36-411.C.  5. In an interview, E1 agreed E2’s personnel record did not contain evidence of documentation of E2’s starting or ending date of employment, E2’s skills and knowledge, orientation, evidence of freedom from infectious TB, or good faith efforts to contact previous employers.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, which was reviewed and updated no later than 14 days after a significant change in the resident’s physical, cognitive, or functional condition, for two of four residents sampled. Findings include: 1. A review of R3’s medical record revealed documentation dated January 7, 2025, titled “Annual Report of Guardian,” which indicated R3 was diagnosed with “dementia and does not have ability to understand reality.” 2. A review of R3’s medical record revealed a current service plan, dated January 11, 2025, which identified R3’s level of care as “Personal.” 3. A review of R4’s medical record revealed a document titled “Written Recertification,” dated February 5, 2025. The document identified R4’s primary diagnosis as “Alzheimer’s Dementia.” The document indicated R4 was experiencing “significant deterioration, with progressive cognitive and functional decline.” 4. A review of R4’s medical record revealed a service plan, dated March 11, 2025, which identified R4’s level of care as “Personal.” 5. In an interview, E1 agreed R3’s and R4’s service plans had not been updated within 14 days, as required, after a change in R3’s and R4’s condition.