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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Behavioral health training was not found for 8 of 8 staff reviewed, including an LPN, a housekeeper, a cook, and multiple CNAs. Records showed they had completed other required training, but surveyors could not locate behavioral health training for any of them. Facility leaders said training was assigned through the training system and monthly in-services, and the NHA stated the facility did not have a training policy.
An LPN’s training record did not include behavioral training during the past year of employment, and the Infection Preventionist confirmed the facility failed to provide behavioral training to one of five direct care staff reviewed.
The facility failed to ensure that multiple staff members received required annual behavioral health training related to dementia care. A Dietary Server, a PTA, and a Speech Therapist had transcripts that did not show the required dementia-related training, and one staff member’s transcript also lacked other required orientation topics such as abuse, infection control, EJA, resident rights, and emergency preparedness. Interviews with the DON and HRD confirmed that these trainings were expected for staff, including therapy and dietary personnel, and the facility policy required training on resident rights, abuse, neglect and exploitation, dementia management, and infection control.
Failure to Provide Behavioral Health Training: Behavioral Health training was not provided for two NAs as required by facility policy and the facility assessment. Personnel records did not show the required annual training for either NA, and HR confirmed the missing training during interview.
Missing Required Alzheimer’s and Dementia Training for DON and NA-C: The facility failed to ensure the DON and an NA-C completed required initial or annual Alzheimer’s/dementia training. Record review showed both staff lacked training on Alzheimer’s disease and related disorders, ADL assistance, problem solving with challenging behaviors, and communication skills. The administrator acknowledged the missing training, while facility orientation materials and the facility assessment identified dementia care topics as part of staff training.
The facility failed to ensure an agency CNA had completed required behavioral health training. Record review showed no documentation of the training, and Administrative Staff B stated the facility expected the agency to provide required training and in-services before scheduling staff. The facility also could not provide a policy related to required staff in-services.
Missing Behavioral Health Training for Multiple Staff
Penalty
Summary
Behavioral health training was not provided for 8 of 8 direct and non-direct staff selected at random. The staff members identified were LPN-OO, Housekeeper-PP, Cook-QQ, CNA-RR, CNA-SS, CNA-TT, CNA-MM, and CNA-UU. Record review showed each of these employees had completed other required training, such as resident rights, abuse, neglect, exploitation, infection control, QAPI, compliance and ethics, communication, and dementia for the CNAs, but surveyors were unable to locate behavioral health training for any of them. During the survey, staff explained that training was assigned through the facility's training system and that in-services were assigned monthly or as needed. The NHA stated she provided one-on-one or shift-to-shift training for other departments along with department heads, and the Senior VP of Clinical Compliance & Quality stated employee training was handled through the support center compliance department. When asked for the facility's training policy, the NHA stated the facility did not have one. The facility was not able to provide behavioral health training records for the 8 staff members reviewed.
Failure to Provide Behavioral Training to Direct Care Staff
Penalty
Summary
The facility failed to provide behavioral training to one of five direct care staff reviewed, an LPN with a hire date of 8/1/24. Review of the LPN’s personnel file showed that the education and training records did not include behavioral training during the past year of employment, as required. During an interview on 6/3/26 at 10:30 a.m., the Infection Preventionist confirmed that the facility failed to provide behavioral training to one of five direct care facility staff.
Missing Required Dementia Care Training for Multiple Staff
Penalty
Summary
The facility failed to ensure that 3 staff members received annual behavioral health training related to dementia care. Staff #44, a Dietary Server hired on 12/16/2024, had no behavioral health training related to dementia care listed on the 2025 transcript history document, and it was not known when that training was completed. Staff #168, a Physical Therapy Assistant hired on 08/01/2024, also had no behavioral health training related to dementia care listed on the transcript document, and it was not known when that training was completed. Staff #182, a Speech Therapist hired on 01/05/2026, likewise had no behavioral health training related to dementia care listed on the transcript document. During the review of her 2026 transcript, no abuse, infection control, Elder Justice Act, emergency preparedness, or resident rights training was listed, and her transcript showed modules on other topics beginning on 03/30/2026, 04/01/2026, 04/22/2026, 04/23/2026, and 05/06/2026. Staff interviews confirmed that the facility expected staff to complete required training modules and that the DON had access to monitor completion. The DON stated that annual training included abuse, infection control, EJA, resident rights, emergency preparedness, and dementia care training, and that the therapy team and dietary staff took the same training as nursing staff. The HRD stated that Staff #168 completed abuse training in 12/2025 but did not see other required trainings for that staff member, and stated that Staff #182’s transcript did not show the required trainings. The facility policy titled Staff Development and Orientation-Resident Care stated that all new and existing staff, volunteers, and contractors would receive training on resident rights, abuse, neglect and exploitation, dementia management, and infection control.
Failure to Provide Behavioral Health Training
Penalty
Summary
Behavioral Health training was not provided for two of three staff members, Nurse Aide Employee E2 and Nurse Aide Employee E3, as required by facility policy and the facility assessment. Review of the facility's Continuing Education policy indicated that compliance with the facility's standards, policies, and procedures is a condition of employment, including compliance with the training program. Review of the Training Requirements-Behavioral Health Training policy indicated that the facility will provide Behavioral Health training. Employee E2's personnel record showed a hire date of 3/12/24, but the current file did not show Behavioral Health training for the period 3/12/25 through 3/12/26. Employee E3's personnel record showed a hire date of 4/5/24, but the current file did not show Behavioral Health training for the period 4/5/25 through 4/5/26. During an interview, Human Resource Employee E9 confirmed that the facility failed to provide Behavioral Health training for these two staff members.
Missing Required Alzheimer’s and Dementia Training for DON and NA-C
Penalty
Summary
The facility failed to ensure that 2 of 8 sampled staff members, the DON and NA-C, had initial or annual Alzheimer's and dementia training. Review of the Employee Roster and job/hire date documents showed the NA-C had a hire date of 2/23/26 and the DON had a hire date of 5/28/24. Review of their Alzheimer's Disease or Related Disorder Training records showed both staff members had not completed training covering an explanation of Alzheimer's disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, or communication skills. During an interview on 5/19/26 at 4:25 p.m., the administrator stated that the 2 of the 8 staff had not completed their Alzheimer's training as required and expected the training to be completed initially and annually. The facility's undated New Hire Requirements for Relias orientation education listed dementia care topics, including understanding dementia, communication, actions and reactions, Alzheimer's/dementia versus normal aging, ADL assistance, challenging behaviors, and caregiver stress management. The 5/12/26 Facility Assessment identified staffing would be adequate for caring for residents with mental health conditions, history of trauma, and dementia, and the facility's training program for new and existing staff included dementia management, abuse prevention, effective communication, special needs of residents, and caring for residents who are cognitively impaired. A policy on the facility's Alzheimer's dementia training program for new hires and annual training was requested but not provided.
Failure to Verify Required Behavioral Health Training for Agency CNA
Penalty
Summary
The facility failed to ensure agency staff received the required behavioral health training consistent with the facility assessment. During record review on 05/14/26, the facility was unable to provide documentation that agency CNA P had completed behavioral health training. During an interview the same day, Administrative Staff B stated she was responsible for scheduling agency staff and that the facility expected the agency to have provided the required training and in-services to its staff before they were scheduled at the facility. The facility was also unable to provide a policy related to required staff in-services when requested.
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