Inadequate Staff Training on Reheating Food Leads to Resident Burn
Summary
The facility failed to ensure appropriate and effective training for staff on reheating resident food, resulting in a resident sustaining a burn from overheated soup. The facility's policy required staff to set the microwave to 30 seconds initially and then 15 seconds for any additional heating, stirring with a clean utensil to ensure even heating, and checking the temperature to ensure it did not exceed 140 degrees Fahrenheit at the time of service. However, a Certified Nurse Assistant (CNA) did not follow this procedure, leading to the resident spilling hot soup on himself and sustaining burns on his lower right abdomen, which required daily dressing changes and wound care consultation. Interviews with staff revealed a lack of understanding and inconsistent knowledge about the reheating procedure, with some staff unaware of the correct temperature guidelines or the existence of the policy. The Director of Nursing (DON) acknowledged that the incident occurred because the CNA did not check the temperature of the soup before serving it. Despite the Assistant Director of Nursing Risk Manager (ADONRM) providing training and conducting audits, several staff members, including agency CNAs, were unable to explain the correct reheating procedure. This indicates that the training provided was not effective or adequately reinforced, leading to the deficiency. The policy was posted in various locations, but staff interviews revealed that some had not received or retained the necessary training to ensure resident safety when reheating food.
Penalty
Resources
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Failure to provide required abuse, neglect, and exploitation training was identified for an NA. Facility policy required annual training covering abuse, neglect, exploitation, misappropriation of resident property, reporting procedures, dementia management, and resident abuse prevention. The NA's personnel file did not show the required annual in-service training, and HR confirmed the training had not been provided.
A facility failed to provide required dependent adult abuse training within 6 months of hire for an RN. Record review showed the RN completed the 2-hour mandatory reporter training after the policy deadline, and the Director of Compliance acknowledged the training was late and said the facility had recently changed its process for enrolling new hires in the class right away.
Failure to provide required Abuse, Neglect, and Exploitation training to five of five direct care staff, including an LPN, three NAs, and an RN. The NHA stated education was tracked by calendar year and that no 2025 training records could be found for the employees reviewed; the HR Director confirmed the training was not provided.
Missing Required Abuse, Neglect, and Exploitation Training: The facility could not provide evidence that 5 CNAs with more than 1 year of service had completed required training on abuse, neglect, and exploitation. The HR Director said HR handled onboarding but not annual training, while the NHA and DOP confirmed there was no evidence of the training and no Staff Development Coordinator or designee maintaining a training schedule or documentation system.
The facility failed to ensure that 1 of 5 staff files reviewed had current DAA Mandatory Reporter's Training. A CMA hired in the facility did not have documentation of completing the required 2-hour abuse reporting training within 6 months of hire, and the Interim Administrator stated he had no other employee file documentation and was aware of concerns with the files.
Failure to Provide Required Dementia Training: The facility did not provide required all-staff dementia training, including management of dementia-related behaviors. Staff reported that the last dementia training was completed about two years ago and that no further dementia education had been provided since then. Record review confirmed the last all-staff dementia care training on file, and the facility did not produce a policy for dementia training requirements by the end of the survey.
Failure to Provide Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide annual in-service training on Abuse, Neglect, and Exploitation for one of three staff members, Nurse Aid (NA) Employee E3. Review of the facility's policy on Continuing Education showed that compliance with facility standards, policies, procedures, and the training program is a condition of employment. Review of the Training Requirements- Abuse, Neglect and Exploitation Training policy showed the facility will include activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, along with procedures for reporting incidents of abuse, neglect, exploitation, misappropriation of resident property, dementia management, and resident abuse prevention. Review of NA Employee E3's personnel record showed a hire date of 4/5/24, and the file did not contain annual in-service training on Abuse, Neglect, and Exploitation for the period 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed the facility failed to provide this training for NA Employee E3.
Late Dependent Adult Abuse Training for New RN
Penalty
Summary
The facility failed to provide dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed. Personnel file review showed Staff F, an RN hired on 8/5/25, completed the 2-hour dependent adult abuse mandatory reporter training on 3/24/26, which was later than the facility policy requirement. The facility policy titled Abuse Prevention, Identification, Investigation and Reporting Policy, reviewed 07/2025, stated each employee must complete 2 hours of training related to identification and reporting dependent adult abuse within six months of initial employment. During interview on 5/20/26 at 10:00 AM, the Director of Compliance acknowledged the training was completed late and stated the facility had recently changed its process so new hires would be enrolled in the DAA class right away instead of waiting 4-6 months.
Failure to Provide Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide Abuse, Neglect, and Exploitation training to five of five direct care staff reviewed, including an LPN, three NAs, and an RN. During interviews, the NHA stated that staff education is tracked by calendar year from January through December and that the State Agency requested employee education records for the identified staff. The NHA later stated the facility was unable to find any education records for those employees for the year 2025, and the HR Director confirmed that the facility failed to provide Abuse, Neglect, and Exploitation training to the five direct care staff reviewed.
Missing Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility did not ensure that 5 of 5 direct care staff reviewed received the required training on abuse, neglect, and exploitation. The staff members identified were CNAs TT, UU, VV, WW, and XX, all of whom had worked at the facility for more than 1 year. The facility was unable to provide evidence that these CNAs had received training on abuse, neglect, and exploitation, despite the facility policy stating that training content includes abuse, neglect, and exploitation prevention, dementia management and care of the cognitively impaired, and other required topics. On 5/4/26, the surveyor reviewed the records of the 5 CNAs selected from a list of employees provided by the facility. The surveyor found that CNA TT, CNA UU, CNA VV, CNA WW, and CNA XX had hire dates between 5/7/2024 and 12/4/2024, but no documentation was available showing they had completed the required training. On 5/5/26, the HR Director stated that HR handled new employee onboarding but did not track annual training after hire, and that annual training should be tracked by nursing. The HR Director also stated there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed the facility had no evidence that abuse, neglect, and exploitation training had been provided, and the NHA stated the training records were in boxes kept by the previous DON and were not organized. The NHA further confirmed there was no Staff Development Coordinator or designee maintaining a training schedule or documentation system for completed trainings.
Missing Required Abuse Reporting Training
Penalty
Summary
The facility failed to ensure that 1 of 5 staff members reviewed for Dependent Adult Abuse (DAA) Mandatory Reporter's Training had current training. Personnel file review showed that Staff J, a Certified Medication Aide with a hire date listed as 8/14/25 on the undated New Hire List and Roster, did not have documentation of completing the required DAA Mandatory Reporter's Training within 6 months of hire. During interview on 5/7/26 at 9:20 a.m., the Interim Administrator stated he had no other employee file documentation and was aware there were concerns with the files. The facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting, dated 3/18/26, stated that within 6 months of hire each employee was required to complete 2-hour DAA training.
Failure to Provide Required Dementia Training
Penalty
Summary
The facility failed to provide required dementia training to all staff, including training on management of dementia-related behaviors. During interview, staff member A stated the last all-staff dementia training was on 8/29/24 and that the next annual training was due on 8/29/25, but all staff had not received dementia training since that date. Staff member A also stated the facility had established a dementia training program but failed to implement it by the due date, and that the expectation was for all staff to receive dementia training at hire and annually thereafter. Staff member V stated the facility used quarterly Workday assignments for training and did not remember doing any specific dementia training. Staff member X stated she had dementia training about two years ago and that no dementia training had been done since then. Record review showed the last all-staff dementia care training was provided on 8/29/24, and the facility did not provide a policy or procedure for staff education and training requirements for dementia care by the end of the survey.
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