Failure to Implement Effective Behavioral Health Training Program
Summary
The facility failed to develop, implement, and maintain an effective training program for all staff, including behavioral health care and services training, as determined by staff need and the facility assessment. This deficiency affected two sampled employees hired within the last year. The facility census was 96. The facility did not provide a policy regarding behavioral health training, and the facility assessment had not been reviewed annually since 2023. Additionally, there was no documentation showing that the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee reviewed the facility assessment. The number of residents with intellectual and/or developmental disabilities was inaccurately reported, and the behavioral healthcare needs, including trauma and PTSD, were also inaccurately documented. The competencies required by the facility did not include essential areas such as catheter care, falls, communication, behavioral health, or meeting the needs of individuals with mental illness or intellectual/developmental disabilities. Review of the medical diagnoses of the 96 residents present during the on-site survey revealed a significant number of residents with various mental health conditions, including schizophrenia, bipolar disorder, anxiety, depression, schizoaffective disorder, history of suicide attempts or suicidal ideations, personality disorder, PTSD, and psychosis. Despite this, there was no documentation of behavioral health training for two Certified Nurse Aides (CNAs) hired within the last year. During interviews, the Assistant Director of Nursing (ADON) admitted that they could not find the in-services from the previous Directors of Nursing (DON) and that the specific training for behavioral residents was unknown. The Administrator acknowledged the need for behavioral health training in the facility.
Penalty
Resources
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The facility failed to ensure that NA-M completed the required Alzheimer's and dementia care training. During record review and interview, the administrator could not locate training documentation for the NA, who had a start date of 9/9/25, and no policy related to the training was provided.
Missing Behavioral Health Training for Staff Member: The facility failed to ensure an employee completed required behavioral health training. Training records showed no evidence the employee completed the course, and interviews confirmed the employee had not finished assigned computerized training. HR and department leadership stated they were responsible for monitoring completion, but both were newly appointed or in training, and the requested annual training policy was not provided.
A facility failed to ensure that 1 of 8 sampled staff members completed the required annual Alzheimer's Disease and Related Disorders training. Review of the training records showed that an NA had not completed the annual Alzheimer's and dementia training, and the administrator confirmed the omission during interview, stating the training is usually assigned through the facility's online program.
Missing Behavioral Health Training for Direct Care Staff: The facility failed to provide required behavioral health training for an LPN and three CNAs whose personnel files were reviewed. Records showed no evidence of the required training, and the HR Coordinator acknowledged the facility could not produce documentation that the staff had completed behavioral health training. The Administrator was later informed of the findings but could not provide evidence to dispute the deficiency.
The facility failed to develop, implement, and maintain an effective behavioral health training program for staff. Review of annual and new hire training showed no behavioral health care training, and the Regional RN verified that no behavioral training program was in place. The Administrator stated the facility cared for many residents with behavioral concerns.
Missing Behavioral Health Training Documentation: The facility failed to document initial or annual Behavioral Health training for 15 of 20 sampled employees, including the DON, AD, SW, Dietary Manager, CNAs, RN, LPNs, and the Infection Preventionist. Personnel records lacked evidence of training upon hire or annually, and the BOM confirmed the missing documentation while stating orientation and annual training were expected under facility policy.
Failure to Document Required Alzheimer's and Dementia Care Training
Penalty
Summary
The facility failed to ensure that 1 of 8 staff members, NA-M, had completed the required Alzheimer's and dementia care training program. During the survey, a request was made for Alzheimer's and/or dementia care training records for eight employees, and the administrator later stated that training could not be found for NA-M, whose start date was 9/9/25. The administrator stated it was the expectation that all staff receive Alzheimer's and/or dementia care training before working with residents and that documentation of the training be maintained. A policy related to Alzheimer's and dementia care training was requested, but none was provided.
Missing Behavioral Health Training for Staff Member
Penalty
Summary
The facility failed to provide required behavioral health training for 1 of 23 sampled staff members, PT F. Review of the facility’s training log showed no evidence that PT F completed behavioral health training, and the personnel record showed a hire date of 01/31/2025. Review of the training log for the previous 12 months also showed no evidence of behavioral health training for PT F. During interviews, the HR D stated she was newly appointed and was still being trained on her duties and did not have access to view or run reports in the computerized training system. CHR E stated annual required training was computer generated quarterly and staff were emailed regarding required completion and delinquent courses, and that HR and department heads were responsible for monitoring completion and reporting delinquent staff. The Administrator stated HR was responsible for reporting staff completion of annual computerized training, but PT F had not completed assigned behavioral health training and he was unable to provide the required training because the assigned training had not been completed. A requested policy regarding annual employee training was not provided prior to exit.
Failure to Complete Required Annual Dementia Training
Penalty
Summary
The facility failed to ensure that 1 of 8 sampled staff members reviewed for annual required Alzheimer's Disease and Related Disorders training had completed the training. Review of the requested annual Alzheimer's and dementia training on 8/30/26 identified that nursing assistant (NA)-E had not completed the required annual training. During an interview on 8/30/26 at 1:30 p.m., the administrator confirmed that NA-E had failed to complete the annual training and stated that the facility typically assigns the training through its online training program, but he had not realized NA-E had not completed the required training. A policy was requested, but none was provided by the end of the survey period.
Missing Behavioral Health Training for Direct Care Staff
Penalty
Summary
The facility failed to provide required behavioral health training for 4 of 5 sampled direct care staff members whose personnel files were reviewed for training requirements. Review of the personnel files for an LPN, three CNAs, and another CNA showed no evidence that behavioral health training had been completed, despite their hire dates being documented in the files. The staff members identified were hired on 04/27/2026, 05/19/2026, 03/19/2026, and 11/16/2023, and the records reviewed did not contain the required training documentation. On 07/20/2026 and again on 07/22/2026, the HR Coordinator was asked to provide the behavioral health training records for the identified staff, but no evidence was produced. During interviews on 07/22/2026, the HR Coordinator stated she was responsible for staff training and ensuring staff received the correct training as required, but also acknowledged the facility could not provide evidence that the staff had received behavioral health training. On 07/23/2026, the Administrator was informed of the findings and could not present documented evidence to dispute the deficient practice.
Lack of Behavioral Health Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program related to behavioral health care and services for 1 of 1 staff training programs reviewed. Review of the facility’s annual and new hire staff training showed no behavioral health care training. Staff 4, the Regional RN, verified on 7/15/26 at 12:30 PM that the facility did not have a behavioral training program in place. Staff 1, the Administrator, stated on 7/15/26 at 12:33 PM that the facility cared for a large number of residents with behavioral concerns.
Missing Behavioral Health Training Documentation
Penalty
Summary
Behavioral Health training was not completed timely for 15 of 20 sampled employees, based on interview, personnel record review, and document review. The facility failed to ensure initial training was documented for Employee #1, #12, #13, #14, #15, #16, and #17, and failed to ensure annual training was documented for Employee #2, #3, #5, #6, #7, #8, #9, and #10. The affected employees included the Administrator, DON, Activities Director, Social Worker, Dietary Manager, CNAs, Infection Preventionist, RN, and LPNs. The personnel records reviewed lacked documented evidence of Behavioral Health training completed upon hire or annually, depending on the employee. On 06/29/2026 at 8:43 AM, the BOM stated there was orientation training upon hire and annual training thereafter, and that agency staff do not go directly through the facility for orientation training. The BOM confirmed that the listed employees' records did not contain documentation showing Behavioral Health training was completed upon hire and annually, and the facility policy titled, Nursing Personnel Education and Training, published 11/2016, stated that education for new employees and contract staff as part of orientation and scheduled annually includes Behavioral Health training.
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