Deficiency in Staff Training on Elopement Risks
Summary
The facility failed to provide documentation of an effective training program tailored to the needs of its resident population, specifically for one resident identified as Resident R1. The facility's policy on staff development mandates that employees must be competent in skills necessary to care for residents' needs, with an ongoing education program addressing residents' problems, needs, and rights. However, the facility did not demonstrate that such a program was effectively implemented, as evidenced by the incident involving Resident R1, who was at risk for elopement due to cognitive impairment and exit-seeking behaviors. Resident R1, who had a BIMS score indicating severe cognitive impairment, was found outside the facility after reportedly pressing buttons to open a door or being let out by another person. Despite being care planned as an elopement risk, the facility's training did not address the specific method used by the resident to exit the building. Interviews with staff and the Nursing Home Administrator confirmed that while education was provided on identifying and care planning for residents at risk of wandering and elopement, it did not cover the actual circumstances of Resident R1's elopement.
Penalty
Resources
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The facility did not maintain an effective training program for new CNAs, as evidenced by two CNAs lacking required education in compliance and ethics, the QA program, behavioral health, and effective communication. Review of personnel files showed missing training modules for these staff members, and HR confirmed that the required training had not been completed. This issue was identified as an incidental finding during a complaint investigation affecting all residents.
A resident sustained injuries, including a fractured humerus, after falling from her wheelchair during transport in a facility bus. The bus driver, lacking proper training, had positioned the resident's wheelchair sideways, contrary to safety protocols. The facility failed to ensure that bus drivers received adequate training on securing wheelchairs and residents, contributing to the incident.
The facility failed to ensure adequate staff training, affecting all 100 residents. Two CNAs had incomplete orientation checklists, missing critical areas like infection control and dementia care. An LPN reported insufficient orientation due to staffing shortages. This deficiency was investigated under Master Complaint Number OH00162102.
Failure to Ensure Required Training for CNAs
Penalty
Summary
The facility failed to maintain an effective training program for staff, affecting all 59 residents in the facility. Record review of personnel files showed that one CNA hired on 12/19/25 did not have documented training in compliance and ethics, the quality assurance program, effective communication, or behavioral health. Another CNA hired on 10/08/25 did not have documented training in compliance and ethics, the quality assurance program, or behavioral health. During an interview on 03/04/26 at 3:04 P.M., the HR staff member confirmed that the required training had not been completed for these CNAs. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791.
Inadequate Bus Driver Training Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff approved to drive the facility bus were appropriately trained on safety mechanisms, which led to an incident involving a resident. Resident #24, who had intact cognition and required maximum assistance for activities of daily living, was being transported in an electric wheelchair. During the transport, the bus driver, BD #118, had to abruptly stop the vehicle to avoid a collision, causing Resident #24 to fall out of her wheelchair and sustain injuries, including a fracture to her right humerus. The investigation revealed that BD #118 had not received adequate training on securing wheelchairs and residents safely in the facility bus. The training materials provided by the facility emphasized the importance of securing wheelchairs facing the front of the vehicle, but BD #118 had positioned Resident #24 facing sideways due to the wheelchair's size and the resident's leg brace. This improper securement contributed to the resident's fall and subsequent injuries. Further review of personnel files indicated that neither BD #118 nor BD #119, another bus driver, had received the necessary training related to resident safety when transporting residents. The facility's Risk Management policy required annual review and acknowledgment by bus drivers, but BD #118 did not review the policy in 2024, and BD #119 had not reviewed it before assuming the bus driver role. The lack of formal training and oversight in ensuring compliance with safety protocols directly contributed to the incident involving Resident #24.
Incomplete Staff Training and Orientation
Penalty
Summary
The facility failed to ensure that staff were adequately trained as required, which had the potential to affect all 100 residents residing at the facility. During a review of employee files, it was found that the orientation checklists for two Certified Nursing Assistants (CNAs) were incomplete. CNA #823, who started on 10/10/24, had numerous sections of the general orientation checklist not checked off, including critical areas such as infection control, dementia and memory care training, wound care, and incident/accident reporting. Similarly, CNA #885, who started on 07/03/24, also had an incomplete orientation checklist with missing sections in infection control, dementia training, and other essential areas. Interviews conducted with the Human Resource Director confirmed that the orientation checklists for the CNAs were partially filled out and not complete as required. Additionally, an interview with an LPN revealed that they did not feel they received proper orientation upon hire, as they were only given an orientation packet to read without any staff going over the information. The LPN was supposed to have a two-day orientation but only received one day due to staffing shortages. This deficiency was investigated under Master Complaint Number OH00162102 and related Complaint Numbers.
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