Liberty Manor Residency, INC

Based on record review, documentation 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. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings Include 1. A record review of E2's personnel record revealed that E2 received no Fall Prevention and Recovery initial nor annual training. 2. A review of the facility's policies and procedures, revealed that there was not a Fall Prevention and Recovery training/policy. 3. In an interview, E2 acknowledged that the health care institution did not develop and administer a training program for all staff regarding fall prevention and fall recovery.

Based on record review, documentation review, and interview, the manager failed to ensure that annual training and education related to recognizing the signs and symptoms of Tuberculosis (TB) was provided to individual employees or volunteers of the health care institution; and annually assessing the health care institution's risk of exposure to infectious Tuberculosis. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E2's personnel file, revealed that there was no Tuberculosis annual training documented. 2. Review of facility documentation revealed no annual no documentation of an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 3. A documentation review of the facility's policies and procedures titled, "Caregiver Orientation and Continuing Education" and "Tuberculosis Infection Control", revealed that there was no mention of the TB annual training. 4. In an interview, E2 acknowledged that there was no annual TB training for employees nor annual assessment by the facility.

Based on observation, documentation review, and interview, the manager failed to ensure that a current written Resident Rights notice was posted. The deficient practice posed a risk if a resident was not properly informed of their rights. Findings Include: 1. During an environmental inspection of the facility, the Compliance Officer observed a form listing the Resident Rights was hanging on the wall near the facility entrance. 2. A documentation review of the Resident Rights form stated under "2.i. Restraint, if not necessary to prevent harm to self or others." 3. In an interview, E1 acknowledged that the posted Resident Rights form did not contain the correct verbiage regarding no restraints and was therefore out of compliance.

Based on observations, documentation review, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection, the Compliance Officer observed that there was no alert on the patio door leading to the backyard area. 3. A review of the facility's Policies and Procedures documentation revealed a policy titled " Awareness to Locate Resident" which stated "Steps to locate a wandering resident: The resident who wanders at all times must have access to an outside area that is secure and allows the resident to be 30 feet away from the facility." And a policy titled, "Directed Care (Wandering Policy)" which stated "3. Alarms and door alarms to alert staff." 4. In an interview, E2 acknowledged that there were no controls or alerts to notify employees of the egress of a resident from the facility.