Aegis at Coconino Assisted Living Home

Based on documentation review, record review, and interview, the manager failed to ensure that an employee working as 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 two caregivers sampled. Findings include: 1. A review of the facility's documentation revealed a document titled “Staff Schedule” dated May 2025 revealed E3 was scheduled to work at the facility the entire month of May 2025. The schedule reflected “E3 and E2 are live in caregivers, shifts start 7 am to 7 am (24 hrs.)”. 2. A review of E3's personnel record revealed a caregiver training certificate issued by Platinum Training Services with program license number ALTP0185, issued December 17, 2017. 3. A review of the NCIA Board’s website showed that the ALTP0185 Platinum Training Services program’s expiration date was August 8, 2013. 4.A review of Tmuniverse website https://azcg.tmutest.com, revealed there was “No matches found” on the caregiver’s public registry for E3. 5. In an interview, E1 reviewed and acknowledged that E3’s personnel record did not contain any other documentation of a valid caregiver certificate available for review at the time of the survey.

Based on record review and interview, the manager failed to ensure, for one of one sampled resident who was unable to ambulate even with assistance, the resident's primary care provider (PCP) or other medical practitioner examined the resident at the onset of the condition or within 30 days before acceptance and at least once every six months throughout the duration of the resident's condition, to determine if the resident's needs could be met based upon a current examination and the assisted living facility's scope of services. Findings include: 1. In an interview, E1 reported R1 was bed-bound due to an inability to ambulate even with assistance since being accepted to the facility. 2. A review of R1’s medical record revealed a service plan dated March 3, 2025, which reflected that R1 was bed-bound. 3. A review of R1's medical record revealed R1 was at the directed level of care. The medical record contained a documented determination dated August 2, 2024, indicating R1's needs could be met by the facility despite R1 being unable to ambulate even with assistance. There was no recent documented determination completed by R1's PCP or a medical practitioner at least every six months throughout the duration of R1's condition. 4. In an interview, E1 acknowledged that the required documentation for R1 was not available for review at the time of the survey.