Failure to Ensure Staff Training in Abuse Prevention and Dementia Management
Summary
The facility failed to ensure all staff participated in an abuse, neglect, and exploitation prevention program and a dementia management training program, with a process in place to track attendance. This deficiency had the potential to affect all residents, with a facility census of 96. The facility could not provide records of the required training. The Assistant Director of Nursing (ADON) admitted that they could not find the in-services from the previous Director of Nursing (DON), and that the DON before that had destroyed paperwork upon quitting. The ADON, who was in charge of training until a new DON could be hired, was unaware of when the last training sessions for abuse, neglect, and exploitation prevention and dementia management had been conducted. The Administrator confirmed that the facility should have documentation of the abuse and neglect training for all staff.
Penalty
Resources
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The facility failed to ensure a CNA received required annual abuse prevention training, as confirmed by training records, staff interviews, and facility policy. A resident’s responsible party reported that the resident complained a night-shift CNA was rude and mean. Review of the CNA’s file showed her last abuse training was completed more than three years earlier, despite the Administrator, DSD, and written policy all stating that abuse and resident rights training must be provided annually and as needed.
The facility failed to ensure that all staff received and completed required training on abuse, neglect, and exploitation. Review of an abuse in-service sign-in sheet showed that less than half of listed nursing staff signed for attendance, and only a few completed post-tests, with no inclusion of social work, dietary, housekeeping, or maintenance staff. A housekeeping/dietary aide and a nursing assistant reported never receiving abuse-related training. The DNS was unable to account for missing post-tests for multiple staff who had signed the in-service sheet and could not produce a post-test for a nursing assistant who had signed. The DNS also stated he was unaware that abuse training was required for all facility staff, not just nursing staff.
Surveyors found that staff were inadequately trained to recognize and report abuse when one resident punched another, causing a facial laceration requiring medical attention, and stated he did so because the other resident tried to have sex with him. Multiple RNs and supervisory staff reported that their annual abuse training addressed only staff-to-resident abuse and that they did not consider resident-to-resident physical or sexual incidents to be abuse. Review of the facility’s policies and training materials confirmed that definitions of physical, psychological, verbal, and sexual abuse were limited to actions by someone other than another patient, resulting in resident-to-resident abuse not being identified or reported as required.
The facility did not follow its policy requiring annual staff training on abuse, neglect, exploitation, and resident rights. Record review showed that an LPN and a CNA, each employed for more than four months, had not completed abuse or resident rights training since their hire dates. The Business Office Manager confirmed they had no such training during the following year, while the Corporate Regional Manager stated that this training was required yearly. The current facility policy specified that all staff must receive training on abuse and abuse prevention, which was not implemented for these employees.
The facility did not ensure that all staff completed required annual abuse training and did not effectively track compliance with these requirements. A nursing assistant hired more than a year prior had no documented annual abuse training, and an RN had not completed abuse training since hire, as shown in their training records. The HR manager reported that unit managers were responsible for staff training completion, that corporate sent quarterly notices about required trainings, and that she provided reminders, but she did not monitor which staff had outstanding training. Facility policy required a designated super registrar to manage training tracking, completion of hire courses before independent work on the floor, and quarterly assignment of annual training requirements.
The facility did not provide required, facility-specific training on abuse, neglect, exploitation, misappropriation, and reporting procedures to contracted and agency staff, despite a policy stating it applied to all caregivers. A hospice CNA observed a resident left wet for an extended period and believed this was neglect but did not report the concern to the facility for ten days. During the survey, an agency CNA reported receiving no supplemental training on the facility’s abuse and neglect policies, and leadership acknowledged that agency staff had not been trained by the facility and that communication with the hospice agency about concerns was lacking.
Failure to Ensure Annual Abuse Prevention Training for CNA
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA 1) completed required annual abuse training, as identified through interviews and record review. Resident 1’s interdisciplinary team (IDT) note documented that the responsible party reported the resident complained that a night-shift CNA was rude and mean. During review of CNA 1’s training records with the Human Resource Assistant, it was confirmed that CNA 1’s last abuse training occurred on 2/7/23, more than three years prior to the survey, and no more recent abuse training could be produced. In separate interviews, the Administrator and the Director of Staff Development both stated that abuse training was required to be completed annually, and CNA 1 also confirmed that her last abuse training before the allegation was on 2/7/23. The facility’s Abuse Prevention Program policy dated 7/22/2021 stated that all new employees must attend resident rights and abuse prevention training during orientation and that such training shall be provided on an annual basis and as needed, which was not followed in the case of CNA 1. This deficiency centers on the facility’s failure to adhere to its own policy and procedure requiring annual in-service training on resident rights and abuse prevention, resulting in CNA 1 not receiving the mandated annual abuse training for more than three years prior to the reported complaint about her behavior toward Resident 1.
Failure to Provide and Document Abuse and Neglect Training for All Staff
Penalty
Summary
The facility failed to provide required abuse and neglect training to all staff, as evidenced by incomplete attendance and testing records and staff reports of never receiving such education. Record review of the most recent abuse in-service training sign-in sheet dated 1/5/2025, titled "Staff Sign Off Sheet for Abuse and Neglect," showed that only 13 of 28 listed nursing staff had signed for attendance, and only three post-tests were completed despite 23 signatures indicating attendance. The sign-in sheet and associated materials did not include the Social Worker, dietary, housekeeping, or maintenance staff. In interviews, a housekeeping/dietary aide (Staff E) and a Nursing Assistant (Staff B) each stated they had never received abuse-related training at the facility. During an interview, the DNS could not explain why 10 staff members who signed the in-service sheet had no completed post-test and could not provide evidence of a completed post-test for Staff B, despite her signature. The DNS also stated he was unaware that abuse training was required for all facility staff and believed it applied only to nursing staff until informed otherwise by the surveyor. No residents or specific patient conditions were mentioned in the report, and the deficiency centers on the facility’s failure to ensure comprehensive and documented abuse, neglect, and exploitation training for all categories of staff.
Failure to Train Staff on Recognition and Reporting of Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure all staff received adequate training on the recognition, prevention, and reporting of all forms of abuse, including resident-to-resident abuse, as required by Federal regulations. Surveyors reviewed an interdisciplinary note for one resident dated 2/7/2026, which documented that this resident was punched in the face by another resident, resulting in a 1.2 cm laceration to the right upper eyebrow that required medical attention. The note further documented that the resident who did the punching told staff, “I punched him early in the morning because he tried to have sex with me,” indicating an alleged attempted sexual contact and a physical assault between residents. During interviews, multiple staff members demonstrated that they did not recognize resident-to-resident physical or sexual incidents as abuse. One RN stated he received annual abuse training that covered only staff-to-resident abuse, reporting, and prevention. Another RN described finding dried blood above a resident’s right eyebrow, being told by that resident that another resident had punched him while he was sleeping, and then being told by the alleged aggressor that he hit the resident because the resident wanted to have sex with him. This RN characterized the incident as a physical altercation rather than abuse and did not consider the allegation of attempted sexual contact to be sexual assault or abuse, despite confirming he had received annual abuse training. Additional interviews with the Registered Nurse Shift Lead, the Program Director, and the Nursing Coordinator showed a consistent belief that only staff-to-resident physical or sexual assault constituted abuse and that residents could not be perpetrators of abuse. Review of the facility’s abuse training materials and policies showed that the definitions of physical, psychological, verbal, and sexual abuse were limited to actions by “someone other than another patient,” and sexual abuse was defined in terms of employee conduct or employee allowance of sexual contact between patients. These policy definitions and training content excluded resident-to-resident abuse, contributing directly to staff’s inability to recognize and report the resident-to-resident physical and alleged sexual assault as abuse for two sampled residents.
Failure to Provide Required Annual Abuse and Resident Rights Training to Staff
Penalty
Summary
The facility failed to implement its abuse policy and procedure requiring annual training on abuse, neglect, exploitation, and resident rights for staff who had been employed more than four months. Record review on 3/6/26 showed that an LPN who started on 4/12/24 and a CNA who started on 7/11/24 had not completed abuse training or resident rights training since their start dates in 2024. During interview, the Business Office Manager confirmed that these two staff members had no abuse or resident rights training in 2025, and the Corporate Regional Manager stated that such training was required to be completed yearly. A facility policy dated 5/6/25, identified by the Administrator as current, indicated the facility would maintain an effective training program for all staff that included, at a minimum, training on abuse and abuse prevention, which was not followed for these two staff members.
Failure to Ensure and Track Completion of Annual Abuse Training for Staff
Penalty
Summary
The facility failed to ensure completion and tracking of required annual abuse training for staff, resulting in two of ten staff reviewed not having current abuse education. A nursing assistant hired on 11/7/25 had no record of completed annual abuse training as of a training record printed on 3/5/26. A registered nurse hired on 8/28/24 had not completed annual abuse training since the date of hire, according to a training record printed on 3/5/26. During an interview, the human resources manager stated that managers were responsible for ensuring their staff completed training, that the corporate office sent quarterly messages regarding required trainings, and that she reminded managers, but she did not track which staff had or had not completed required training. The facility’s Regulatory and Compliance Education policy dated 5/1/24 stated that each community should assign an associate to the super registrar role to manage tracking of the training system, that assigned hire courses should be completed before an associate works independently on the floor, and that annual requirements are established and assigned quarterly.
Failure to Train Contracted and Agency Staff on Abuse, Neglect, and Reporting Requirements
Penalty
Summary
The facility failed to provide required training to all staff, including contracted and agency personnel, on dementia care and on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting such incidents and resident abuse prevention. The facility’s Abuse policy, revised April 2025, states that it applies to all staff, including employees, consultants, contractors, volunteers, students, and other caregivers, and requires that care and services be delivered in a way that promotes residents’ rights to be free from abuse, neglect, misappropriation, exploitation, or privacy violations. Despite this policy, the regional nurse consultant was unable to produce documentation of facility-specific abuse training for contracted or agency staff and stated that these staff were educated on abuse only by their agencies prior to working at the facility. Record review showed an allegation of neglect initiated by a hospice CNA, who believed a resident receiving care from him and his contracted hospice provider was being neglected by the facility when the resident was left wet for an extended period. The incident report documented that the hospice CNA observed suspected neglect on 11/9/25 but did not report it to the facility until 11/19/25, a delay of ten days. The facility’s investigation concluded that the contracted hospice CNA failed to report suspected neglect in a timely manner. In interviews, an agency CNA confirmed she had not received any supplementary training from the facility on facility policies or expectations related to abuse and neglect, and the regional nurse consultant and DON acknowledged that the facility had not provided abuse-reporting training to agency staff and needed better coordination with the hospice agency regarding communication of concerns.
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