Oasis at Norterra LLC

Based on the documentation review, record review, and interview, the health care institution failed to administer a training program for one of the three staff sampled regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety were not implemented. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Fall Prevention and Recovery" that stated "Fall Prevention and Recovery Training is required upon hire and at least every 12 months thereafter". 2. A review of E4's personnel record revealed a hire date of August, 2023. E4's record revealed fall prevention and fall recovery for 2023 and 2025. However, the record did not contain documentation of fall prevention and fall recovery training for 2024. 3. In an interview, E1 acknowledged that the facility failed to administer a fall prevention and fall recovery training for all staff upon hire and at least every 12 months thereafter.

Based on documentation review and interview, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of facility documentation revealed an incident report dated March 10, 2024. The report stated: "Resident was trying to get up from wheel chair when lost [R2's] balance and slid out of the chair...Asked resident what happened, evaluated for pain and/or injury, called 911." The incident report indicated facility contacted emergency responders on behalf of R2. 2. In an interview, E3 reported the fire department showed up to lift R2 from the floor and requested the documentation required by this statute. When the Compliance Officer asked if E3 provided the emergency responder with the standardized form required by this statute, E3 stated, "We gave [the emergency responder] the binder," referring to R2's medical record. E3 reported the emergency responder did not go through the binder to find the information. E1 later reported not knowing whether E3 provided the standardized form required by this statute to the emergency responder, stating, "Nothing was filled out or copied."

Based on documentation review and interview, the health care institution failed to provide appropriate first aid before the arrival of emergency medical services to a non-injured resident who had fallen, appeared to be uninjured, and was unable to reasonably recover independently. Findings include: 1. A review of facility documentation revealed an incident report dated March 10, 2024. The report stated: "Resident was trying to get up from wheel chair when lost [R2's] balance and slid out of the chair...Asked resident what happened, evaluated for pain and/or injury, called 911." 2. In an interview, E1 reported the caregivers on duty called 911 because the caregivers could not lift R2 from the floor. E1 reported the fire department lifted R2 from the floor back into R2's chair.

Based on interview, record review, and documentation 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 four sampled caregivers. The deficient practice posed a risk if an employee was unqualified to provide caregiving services. Findings include: 1. In an interview, E1 reported E3 was a caregiver. 2. A review of facility documentation revealed a series of personnel schedules which revealed E3 worked regularly as a caregiver between August 2023 and July 2024. 3. A review of E3's personnel record revealed a "CAREGIVER TRAINING" certificate from "Platinum TRAINING SERVICES, LLC...Altp-0191" dated as issued on February 10, 2011. The review further revealed a printout of a search result from the NCIA Board website with a star added next to "Platinum Training Services." However, the document indicated Platinum Training Services was registered as ALTP-0185 and not ALTP-0191 and was not active on the date the certificate was issued. 4. A review of Department documentation revealed Platinum Training Services was not active on the date the certificate was issued. 5. A review of the caregiver certificate verification website (azcg.tmutest.com) revealed no valid caregiver certificate under E3's name. 6. In an interview, E1 reported E1 checked the NCIA Board website before hiring E3 but did not realize the ALTP numbers did not match or that the training program was not active when the certificate was issued.

Based on interview and record review, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9). Findings include: 1. In an interview, E1 reported the facility had forms that were given to emergency responders when the assisted living home contacted an emergency responder on behalf of a resident. However, E1 reported not knowing whether any of the residents had a copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living home to plan for a resident's discharge. 2. A review of R1's and R2's medical records revealed the aforementioned forms. However, R1's form did not include the address of R1's current pharmacy and both R1's and R2's forms did not include a copy of the R1's and R2's HIPAA release form required by this statute.