Brightest Light Senior Living

Based on documentation review, record review, and interview, the manager failed to ensure all staff were administered fall prevention and fall recovery training for one of three personnel reviewed. The deficient practice posed a risk to the physical health and safety of a resident. 1. A review of facility documentation revealed a policy titled, "Fall Prevention and Recovery Training." The policy stated, "To develop and administer a training program for all caregivers/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 revealed annual documentation of fall prevention and fall recovery training was not available for review. 3. In an interview, E1 acknowledged annual documentation of fall prevention and fall recovery training for E2 was not available for review.

Based on record review, documentation review, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed R1 received medication administration services. 2. A review of R1's medical record revealed a signed medication order for Hydroxyzine 50 milligrams (mg), 1 capsule (cap) per oral (PO) every day (QD) dated October 18, 2024. 3. A review of the medication administration record (MAR) for the month of October revealed no documentation of administration of Hydroxyzine 50 mg, 1 cap PO QD from October 19, 2024 through October 24, 2024. 4. A review of facility documentation revealed a policy titled "Medications." The policy stated, "The trained caregiver will initial in the MAR for the date and time the medication was given to the resident and the medications taken." 5. In an interview, E1 reported the Hydroxyzine 50 mg was administered but not documented. While on-site, E1 printed a second page of R1's MAR, which showed the Hydroxyzine 50 mg had been previously added but stated E1 had failed to print it out at the time E1 added it. E1 acknowledged E1 failed to document the Hydroxyzine 50mg as administered.