Aberdeen Home, L L C

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of three caregivers sampled. The deficient practice posed a risk if an employee was unqualified to provide caregiving services, and the Department was provided false or misleading information. Findings include: 1. A review of Department documentation revealed a Statement of Deficiencies (SOD) for an inspection conducted at this facility on October 31, 2023. The SOD stated the following: "[E4's] personnel record revealed a photocopy of a caregiver certificate with [E4's] name on it as the recipient. The document was dated August 13, 2020, and contained a border on the left, bottom, and right sides of the page, but not on the top. On each of the three sides containing a border, the border was disjointed at multiple places. The document contained a "Validation Code" used to validate the certificate. A review of the caregiver certification verification website (az.tmuniverse.com) revealed the certificate in [E4's] personnel record belonged to [another individual] and not [E4]. The review revealed no documentation of [E4's] completion of a caregiver training program approved by the NCIA Board." 2. In a series of interviews, multiple residents reported E4 worked as a caregiver. 3. A review of facility documentation revealed a personnel schedule dated January 2024. The schedule revealed E4 worked the night shift (6:00 PM to 6:00 AM) alone as a caregiver on January 6-7 and 7-8, 2024. 4. A personnel record review revealed no personnel record for E4, including no documentation of completion of a caregiver training program approved by the Department or the NCIA Board. 5. A review of az.tmuniverse.com revealed no valid caregiver certificate under E4's name. 6. In the exit interview, when the Compliance Officers asked if E4 worked alone as a caregiver at night, E3 stated, "Yes" and "[E4] is the night shift." E2 and E3 confirmed E4 worked at the facility as a caregiver. This is a repeat deficiency from the compliance and complaint inspection conducted on October 31, 2023.

Based on documentation review, interview, and record review, the manager failed to ensure an assisted living facility had caregivers with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services and ancillary services in the assisted living facility's scope of services, meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. A review of Department documentation revealed a Statement of Deficiencies (SOD) for an inspection conducted at this facility on October 31, 2023. The SOD stated the following: "[E4's] personnel record revealed a photocopy of a caregiver certificate with [E4's] name on it as the recipient. The document was dated August 13, 2020, and contained a border on the left, bottom, and right sides of the page, but not on the top. On each of the three sides containing a border, the border was disjointed at multiple places. The document contained a "Validation Code" used to validate the certificate. A review of the caregiver certification verification website (az.tmuniverse.com) revealed the certificate in [E4's] personnel record belonged to [another individual] and not [E4]. The review revealed no documentation of [E4's] completion of a caregiver training program approved by the NCIA Board." 2. In a series of interviews, multiple residents reported E4 worked as a caregiver. 3. A review of facility documentation revealed a personnel schedule dated January 2024. The schedule revealed E4 worked the night shift (6:00 PM to 6:00 AM) alone as a caregiver on January 6-7 and 7-8, 2024. 4. A personnel record review revealed no personnel record for E4, including no documentation of E4's qualifications, experience, skills, and knowledge or E4's completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. 5. A review of az.tmuniverse.com revealed no valid caregiver certificate under E4's name. 6. In the exit interview, when the Compliance Officers asked if E4 worked alone as a caregiver at night, E3 stated, "Yes" and "[E4] is the night shift." E2 and E3 confirmed E4 worked at the facility as a caregiver. Technical assistance was provided on this rule during the compliance and complaint inspection conducted on October 31, 2023.

Based on interview, documentation review, and record review, the manager failed to maintain a personnel record for each employee, for one of four employees sampled. The deficient practice posed a risk as required information could not be verified. Findings include: 1. In a series of interviews, multiple residents reported E4 worked as a caregiver. 2. A review of facility documentation revealed a personnel schedule dated January 2024. The schedule revealed E4 worked the night shift (6:00 PM to 6:00 AM) alone as a caregiver on January 6-7 and 7-8, 2024. 3. A review of facility personnel records revealed no personnel record for E4. 4. In the exit interview, when the Compliance Officers asked if E4 worked alone as a caregiver at night, E3 stated, "Yes" and "[E4] is the night shift." E2 and E3 confirmed E4 worked at the facility as a caregiver. Technical assistance was provided on this rule during the compliance and complaint inspection conducted on October 31, 2023.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, for two of eight total residents. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R5's and R8's medical records revealed service plans for R5 (dated as created on August 15, 2022, and updated on February 5, 2023, and August 5, 2023) and a service plan for R8 (dated as created on September 8, 2023). However, the service plans did not include what level of service R5 and R8 were expected to receive. 2. In an interview, E2 reported R5 and R8 received personal care services. E2 and E3 acknowledged the service plans of R5 and R8 did not include the level of service.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the frequency of assisted living services being provided to the resident, for eight of eight total residents. The deficient practice posed a risk as the service plans did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's, R2's, R3's, R4's, R5's, R6's, R7's, and R8's medical records revealed current service plans. However, the service plans revealed the following: -R1's service plans (dated as created on December 21, 2021, and updated on June 10, 2022, December 16, 2022, June 10, 2023, and December 10, 2023) did not include the frequency of assistance with dressing or medication administration; -R2's service plans (dated as created on October 14, 2021, and updated on January 14, 2022, April 14, 2022, July 14, 2022, October 14, 2022, January 14, 2023, April 14, 2023, and July 14, 2023) did not include the frequency of assistance with dressing or medication administration; -R3's service plans (dated as created on June 21, 2022, and updated on December 21, 2022, and June 21, 2023) did not include the frequency of assistance with dressing or medication administration; -R4's service plans (dated as created on April 14, 2023, and updated on October 14, 2023) did not include the frequency of assistance with dressing or medication administration; -R5's service plans (dated as created on August 15, 2022, and updated on February 5, 2023, and August 5, 2023) did not include the frequency of medication administration; -R6's service plans (dated as created on July 11, 2022, and updated on January 11, 2023, July 11, 2023, and January 11, 2024) did not include the frequency of assistance with dressing or medication administration; -R7's service plans (dated as created on September 1, 2021, and updated on March 1, 2022, September 1, 2022, March 1, 2023, and September 1, 2023) did not include the frequency of assistance with dressing or medication administration; and -R8's service plan (dated as created on September 8, 2023) did not include the frequency of assistance with dressing or medication administration. 2. In an interview, E2 and E3 acknowledged the aforementioned service plans did not include the frequency of all assisted living services provided to R1, R2, R3, R4, R5, R6, R7, and R8. Technical assistance was provided on this rule during the compliance and complaint inspection conducted on October 31, 2023.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative when initially developed and when updated, for five of eight total residents. The deficient practice posed a risk if a resident was unable to exercise the right to participate or have the resident's representative participate in the development of, or decisions concerning, the resident's service plan. Findings include: 1. A review of R2's, R3's, R4's, R5's and R8's medical records revealed current service plans. However, the service plans revealed the following: -R2's service plans (dated as updated on January 14, 2022, April 14, 2022, July 14, 2022, October 14, 2022, January 14, 2023, April 14, 2023, and July 14, 2023) indicated the service plans were sent by email or shared. However, these service plans did not include a signature and date from the resident or representative; -R3's service plan (dated as updated on June 21, 2023) did not include a signature and date from the resident or representative; -R4's service plans (dated as created on April 14, 2023, and updated on October 14, 2023) indicated the service plans were reviewed by phone. However, these service plans did not include a signature and date from the resident or representative; -R5's service plans (dated as created on August 15, 2022, and updated on February 5, 2023, and August 5, 2023) indicated the service plans dated August 15, 2022 and February 5, 2023 were reviewed by phone. However, these service plans as well as the service plan dated August 5, 2023, did not include a signature and date from the resident or representative; and -R8's service plan (dated as created on September 8, 2023) indicated the service plan was reviewed by phone. However, the service plan did not include a signature and date from the resident or representative. 2. In an interview, E1, E2, and E3 acknowledged R2's, R3's, R4's, R5's, and R8's service plans were not signed and dated by the residents or residents' representatives when initially developed and when updated.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for eight of eight total residents. The deficient practice posed a risk to the health and safety of the residents as the residents were not provided with the required services. Findings include: 1. A review of R1's, R2's, R3's, R4's, R5's, R6's, R7's, and R8's medical records revealed current service plans and documentation of assisted living services provided to R1, R2, R3, R4, R5, R6, R7, and R8 dated November 2023 through January 2024 titled "ACTIVITIES OF DAILY LIVING FLOWSHEET" (ADLs). The review revealed the following: -R1, R2, R3, R4, R5, R6, R7, and R8 were to receive hair care daily. However, the ADLs included no documentation of this service; -R1, R2, R3, R4, R5, R6, R7, and R8 were to receive nail care daily. However, the ADLs revealed nail care was not documented as provided on some days and documented as not provided on others; -R8 was to receive showers twice per week with partial baths being given "On days when complete bath is not given." However, the ADLs revealed R8 received only two showers in November 2023 and zero showers in December 2023, with partial baths or bed baths being provided on all other days R8 was at the facility; and -R8 was to receive catheter care every four to six hours. However, the ADLs included no documentation of this service. 2. In an interview, E2 and E3 reported showers, partial baths, and bed baths were three distinct services. E2 and E3 reported a shower meant the resident was moved to a bathroom, got in the shower, and was washed there; a partial bath meant the resident was not moved to the shower but instead a wet rag was used to clean portions of the resident's body; and a bed bath meant the resident stayed in bed and received a bath there, including washing the resident's hair. E2 reported R8 never got showers, but only received partial baths and bed baths, contradicting the November 2023 ADLs. E2 and E3 reported not documenting R8's catheter care. E2 and E3 acknowledged the manager failed to ensure a caregiver or assistant caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record. This is a repeat deficiency from the compliance and complaint inspection conducted on October 31, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "MEDICAL RECORDS" dated December 2, 2022. The policy and procedure stated, "A resident's medical record was protected from loss, damage, or unauthorized use." 2. During the environmental inspection of the facility, the Compliance Officer observed an unlocked office adjacent to the dining room. Inside the room, the Compliance Officer observed unprotected resident records. The Compliance Officer also observed unprotected resident records on a counter in the open kitchen. 3. In an interview, E2 and E3 acknowledged the records were not protected from loss, damage, or unauthorized use. Technical assistance was provided on this rule during the compliance and complaint inspection conducted on October 31, 2023.

Based on record review and interview, the manager failed to ensure the requirements in Arizona Administrative Code (A.A.C.) R9-10-814(B)(2) were met for a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, for one of three non-ambulatory residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A.A.C. R9-10-814(B)(2) states, in part: "B. A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: 2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: a. The resident or resident's representative requests that the resident be accepted by or remain in the assisted living facility; b. The resident's primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition: ii. Reviews the assisted living facility's scope of services; and iii. Signs and dates a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility." 2. A review of R1's medical record revealed service plans (dated as created on December 21, 2021, and updated on June 10, 2022, December 16, 2022, June 10, 2023, and December 10, 2023). The service plans stated R1 was "Wheelchair/Chair bound." The review revealed written determinations from a medical practitioner dated December 10, 2021, June 10, 2022, December 10, 2022, June 10, 2023, and December 10, 2023. Each of the determinations stated, "The resident's needs are being met by the staff of this Assisted Living Home and I wish for him/her to reside at [the facility]" and included a place for the resident or resident's representative to sign and date the determination. However, the review revealed the following: -R1 or R1's representative did not sign or date any of the determinations after December 21, 2021, signifying a request for the resident remain in the assisted living facility; and -The determination dated December 10, 2023, was not signed or dated by R1's primary care provider or other medical practitioner. 3. In an interview, E1 reported R1 was unable to ambulate even with assistance since R1's acceptance. E1 acknowledged R1's medical practitioner did not provide a written determination at least once every six months.

Based on observation, interview, and record review, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented the information required by this rule. The deficient practice posed a risk of potential re-injury. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed R8 was not present at the facility. 2. In an interview, E1 reported R8 was transported to the hospital and was not in the facility. 3. In a separate interview, E2 and E3 confirmed R8 was taken to the hospital a few weeks prior to the inspection and had been in the hospital for approximately two weeks in mid-December 2023 as well. When the Compliance Officers asked if any documentation was available regarding the incident or R8 going to the hospital, E3 reported the facility had no such documentation. E2 and E3 reported other residents were recently taken to the hospital as well and no documentation was made for those incidents either. 4. A review of R8's medical record revealed no incident reports including the following: -The date(s) and time(s) of the accidents, emergencies, or injuries; -A description of the accidents, emergencies, or injuries; -The names of individuals who observed the accidents, emergencies, or injuries; -The actions taken by the caregiver or assistant caregiver; -The individuals notified by the caregiver or assistant caregiver; and -Any action taken to prevent the accidents, emergencies, or injuries from occurring in the future. 5. In an interview, E2 stated, "That's the one thing we don't document here, going to the hospital."

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. The deficient practice posed a risk to the health and safety of the residents as an uncovered garbage container can lead to the possibility of infection. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed garbage in uncovered containers lined with plastic bags in the living room and in R7's bedroom. 2. In an interview, E2 and E3 acknowledged the garbage containers were not covered. E2 reported E2 told E1 about the uncovered garbage containers the week after the inspection conducted on October 31, 2023, but nothing was done. Technical assistance was provided on this rule during the compliance and complaint inspection conducted on October 31, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of six caregivers sampled. The deficient practice posed a risk if an employee was unqualified to provide caregiving services, and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Staffing, Hiring, and Discipline" dated December 2, 2022. The policy and procedure stated: "Upon being hired by the facility the applicant must: Be certified in the level of care services the Assisted Living Facility is licensed to provide (Supervisory, Personnel, Directed,) and provide Original certificate for verification, Copies to be made by facility." The review further revealed a policy and procedure titled "Manager's Responsibilities" dated December 2, 2022. The policy and procedure stated, "The Manager shall: Ensure that all employees have the required documentation, skills and training to perform the positions they are hired for." 2. A review of facility documentation revealed a series of personnel schedules dated between June 1, 2023, and October 31, 2023. The schedules revealed E5 worked alone as a caregiver for one hour on June 6-7, 2023, July 8, 2023, August 14, 18, 21, and 28, 2023, September 4, 11, 18, and 25, 2023, and October 2, 9, 16, 23, and 30, 2023. The schedules further revealed E5 worked alone as a caregiver for 12 hours on October 1, 7-8, 14-15, 21-22, and 28-29, 2023. 3. A review of E5's personnel record revealed an application for employment. The document stated the following: -"Position applying for" with "CARE GIVER" [ sic ] written in pen on the line to the right; -"Training & Certifications" with "N/A" written in pen on the line to the right; -"Are you a US citizen or an alien authorized to work in the United States?" with a check mark written in pen above the option "No;" -Two places for E5 to provide work experience and professional references, including the employer's name, address, and telephone number, as well as the position held and dates employed, with "N/A" written across the lines to the right of both spaces; -"TO BE COMPLETED BY MANAGER: Date & Time Verified" with the date written in pen on the line to the right; and -"TO BE COMPLETED BY MANAGER: Comments" with "No previous work experience in USA" written in pen on the line to the right. 4. A review of E5's personnel record revealed a photocopy of a caregiver certificate with E5's name on it as the recipient. The document was dated August 13, 2020, and contained a border on the left, bottom, and right sides of the page, but not on the top. On each of the three sides containing a border, the border was disjointed at multiple places. The document containe

Based on documentation review, record review, and interview, the manager failed to ensure a manager provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of one managers sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "CPR and First Aid" dated December 2, 2022. The policy and procedure stated: "Employees and volunteers shall provide documentation of CPR (Cardiopulmonary resuscitation) and First Aid Training...The Owner and/or Manager shall ensure that all employees and volunteers that require CPR and First Aid training renew their certificates /Cards in a timely manner prior to the expiration date. A copy of the front and back of the CPR and First Aid Certification/Card shall be kept in the employees [ sic ] or volunteer's files." The review further revealed a policy and procedure titled "JOB DESCRIPTION: MANAGER" dated December 2, 2022. The policy and procedure stated: "Qualifications/Education: CPR and First Aid." 2. A review of E1's personnel record revealed a series of first aid and CPR training certificates. However, the most recent certification expired on May 13, 2023. There was no documentation of current first aid or CPR training available for review. 3. A review of the medical records for R1 and R2 revealed service plans signed by E1 after May 13, 2023. 4. In an interview, E2 and E3 acknowledged E1's documentation of first aid training and CPR training was expired.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for three of three residents sampled. The deficient practice posed a risk to the health and safety of the residents as the residents were not provided with the required services. Findings include: 1. A review of the medical records of R1, R2, and R3 revealed service plans for R1, R2, and R3 and documentation of assisted living services provided to R1, R2, and R3 in October 2023, titled "ACTIVITIES OF DAILY LIVING FLOWSHEET" (ADLs). R1's service plan, dated July 11, 2023, stated R1 was to receive a "Shower 2x/week by CG;" "Nail Care Check finger nails daily and clean as needed, Trim finger nails as needed, Check nails after each complete bath and clean as needed, Trim toe nails as needed;" and "Comb Hair Daily." However, R1's ADLs revealed the following: -R1 received a "SHOWER" on October 4, 18, and 30, 2023; -R1 received a "PARTIAL [bath]" on all other days in October 2023; -A place to document "NAIL CARE [HAND]" (brackets in original text), but no documentation of checking, cleaning, or trimming R1's fingernails; -No place to document trimming R1's toenails; and -No place to document combing R1's hair. R2's service plan, dated September 1, 2023, stated R2 was to receive a "Shower 2x/week Dependent by CG;" "Nail Care Check finger nails daily and clean as needed, Trim finger nails as needed, Check nails after each complete bath and clean as needed, Trim toe nails as needed;" and "Comb Hair Daily." However, R2's ADLs revealed the following: -R2 received a "SHOWER" on October 3, 10, 24, and 26, 2023; -R2 received either a "PARTIAL [bath]" or a "BED [bath]" on all other days in October 2023; -A place to document "NAIL CARE [HAND]" (brackets in original text), but no documentation of checking, cleaning, or trimming R2's fingernails; -No place to document trimming R2's toenails; and -No place to document combing R2's hair. R3's service plan, dated June 10, 2023, stated R3 was to receive "Nail Care Check finger nails daily and clean as needed, Trim finger nails as needed, Check nails after each complete bath and clean as needed, Trim toe nails as needed;" and "Comb Hair Daily." However, R3's ADLs revealed the following: -A place to document "NAIL CARE [HAND]" (brackets in original text), but no documentation of checking, cleaning, or trimming R3's fingernails; -No place to document trimming R3's toenails; and -No place to document combing R3's hair. 2. In an interview, E2 and E3 reported showers, partial baths, and bed baths were three distinct services. E2 and E3 reported a shower meant the resident was moved to a bathroom, got in the shower, and was washed there. E2 and E3 reported a partial bath meant the resident was not moved to the shower but instead a wet rag was used to clean portions of the

Based on documentation review, interview, and record review, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of three residents sampled. The deficient practice posed a risk of an adverse health condition due to a medication not being administered as ordered or documented as administered. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "RECORDING AND MAINTENANCE OF MEDICATION RECORDS" dated December 2, 2022. The policy and procedure stated, "Medication administration is documented on the resident's MAR at the time the medication is given by the person administering the medication." The review further revealed a policy and procedure titled "MEDICATION ERRORS" dated December 2, 2022. The policy and procedure stated, "All medication prescriptions will be checked against the doctors' orders prior to administration; the MARS will also be checked to ensure that it matches both the order and the prescription." 2. In an interview, E2 reported all residents received medication administration services. 3. A review of R1's medical record revealed a service plan dated July 11, 2023. The service plan stated R1 was to receive "Medication Administration under the direction of Resident's Primary Physician." The review revealed medication orders for the following medications: -"Lisinopril Tablet 20 MG (milligrams) Give 2 tablet[s] by mouth one time a day" dated July 7, 2022; -"Miconazole Nitrate Cream 2 % Apply...two times a day" dated July 7, 2022; and -"Triamcinolone acetonide 0.1 % topical cream application on the skin daily to spot on the neck" dated December 19, 2022. 4. A review of R1's medical record revealed a medication administration record (MAR) dated October 2023 and a document titled "PRN FLOWSHEET" dated between May 7, 2023, and September 1, 2023. The documents revealed the following: -No documentation of the administration of R1's "Lisinopril"; -R1 received "2 tabs [of] anti diarrhea [loperamide]" on June 2 and 30, 2023, and July 13, 2023, without an order; -R1 did not receive the first dose of R1's "Miconazole" on October 1-3, 6, 13-14, 23, and 27-31, 2023; -R1 did not receive the second dose of R1's "Miconazole" on October 1-3, 23, and 27-30, 2023; and -No documentation of the administration of R1's "Triamcinolone". 5. In an interview, E2 and E3 reported R1 received R1's "Lisinopril" and "Triamcinolone" as ordered but the administration was not documented. E2 reported E6 administered R1's "Triamcinolone". E2 reported R1 did not receive R1's "Miconazole" two times a day as ordered, but instead received it when R1 requested it. E2 and E3 acknowledged R1 received "Loperamide" without a medication order.