Biltmore Care Home, LLC

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training, for two of three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Fall Prevention and Fall Recovery Training." The policy stated, "1. Biltmore Care Home, as a licensed healthcare institution, has developed and administers a training program for all caregiving staff regarding fall prevention and fall recovery. The training program requires initial training and continued competency review on an annual basis in fall prevention and fall recovery." 2. A review of E2's personnel record did not include documentation of fall prevention and fall recovery training. Based on E2's date of hire, an initial and annual training was required. 3. A review of E3's personnel record did not include documentation of fall prevention and fall recovery training. Based on E3's date of hire, an initial and annual training was required. 4. In an interview, E1 reported when training was conducted E1 removed the prior fall prevention and fall recovery certificate and did not place the new certificates in the personnel records. E1 acknowledged that the facility failed to administer a training program for all staff regarding fall prevention and fall recovery that included initial training.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a review date of February 6, 2021. No documentation of further review was available for Compliance Officer review. 2. In an interview, E1 reported E1 had updated policies as changes were made although E1 had not documented a review. E1 acknowledged that the polices and procedures were not reviewed at least once every three years and updated as needed.

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for three of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1's personnel record revealed E1 completed training on recognizing the signs and symptoms of TB on May 30, 2022. However, documentation of additional training was not available for review. 2. A review of E2's and E3's personnel record revealed E2 and E3 completed training on recognizing the signs and symptoms of TB on September 1, 2023. However, documentation of additional training was not available for review. 3. In an interview, E1 acknowledged E1's, E2's, and E3's personnel record did not include documentation of annual training on recognizing the signs and symptoms of TB.

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. A review of facility policies and procedures revealed a policy titled "Tuberculosis Screening" which stated: - "d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis." A further review of the policy revealed unfilled document titled "Appendix 1. Facility Risk Assessment" for annual completion. 2. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available. 3. In an interview, E1 reported E1 had not completed the annual risk assessment. E1 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted annually.