Bright Valley Group Home at Elliot Groves

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. Findings include: 1. A review of the facility documentation revealed an undated document titled "FALL PREVENTION AND RECOVERY." However, the training policy and procedure did not include the initial training and continued competency training requirement. 2. In an interview, E1 acknowledged the facility's fall prevention and fall recovery training program did not include the initial training and continued competency training requirement.

Based on record review and interview, the manager failed to ensure a caregiver who had or was expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three caregivers sampled. The deficient practice posed a TB exposure risk to residents. Findings include: R9-10-113(B) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC), ii. Was administered within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution, and iii. Includes the date and the type of tuberculosis screening test; b. If the individual had a history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, compliance with subsection (A)(2)(b); or c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R96-101; and ii. Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution; 1. A review of E4's (hired in 2022) personnel record revealed a document dated in August 2022 signed by a medical practitioner. The document stated "Upon clinical examination, patient has no evidence of pulmonary disease and free of TB ..." 2. A review of E4's personnel record revealed a document dated in August 2022 titled "EMPLOYEE TUBERCULOSIS / INFECTIOUS DISEASE SCREENING / SURVEILLANCE." The document revealed the following "TUBERCULOSIS SCREENING" questions marked with an "x": -No unexplained cough for more than 3 weeks, chest pain, bloody sputum, loss of appetite, weight loss, night sweats, fever or fatigue. -Negative skin test within 30 days. Date: However, documentation of E4's evidence of freedom from infectious TB was not available for review. 3. In an interview, E1 acknowledged E4 had not provided documentation of freedom from infectious TB.

Based on record review and interview, the manager failed to ensure a service plan for a resident receiving directed care services included strategies to ensure a resident's personal safety, for two of two residents sampled who received directed care services. Findings include: 1. A review of R2's (admitted in 2022) medical record revealed a service plan signed and dated in April 2023. However, the service plan did not include strategies to ensure R2's personal safety. 2. A review of R3's (admitted in 2023) medical record revealed a service plan signed and dated in May 2023. However, the service plan did not include strategies to ensure R3's personal safety. 3. In an interview, E1 acknowledged R2's and R3's service plans did not include strategies to ensure R2's and R3's personal safety.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed five ambulatory residents on the premises. 2. The Compliance Officer observed a lockbox in the unlocked kitchen refrigerator contained a key in the unlocked position. The lockbox contained the following medications: -Lorazepam 2 mg oral concentrate; -Novolog insulin injection vial belonging to R1; and -Lispro Insulin injection vial. 3. In an interview, E1 acknowledged the medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.