Hilda's Haven Alf #3

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of facility documentation revealed a document labeled "Fall prevention and recovery training programs." The program stated "All employees will have an initial training on fall prevention and recovery. After initial training, all employees will be required to attend continuing competency training on fall prevention and recovery at least every 12 months. Completion of the training shall be documented and included in the employee files." 2. A review of E1's personnel record revealed documented fall prevention and recovery training dated May 2022. However, E1's personnel record did not include a current annual training for fall prevention and recovery as required per the documented program. 3. In an interview, E3 acknowledged the facility's fall prevention and fall recovery program was not administered according to the documented program requirements.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. A review of facility documentation revealed a policy and procedure manual labeled "Hilda's Haven of Coronado Ranch LLC DBA: Hilda's Haven ALF #3 Policy and Procedures." The documentation indicated the most recent review date was March 22, 2020. 2. In an interview, E3 acknowledged the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed.