Deficiency in Staff Training Documentation
Summary
The facility failed to ensure that personnel records for two staff members, a registered nurse and an activity coordinator, included documentation of required orientation and in-service education. The registered nurse, hired in April 2021, had no evidence of infection control and abuse/neglect/exploitation training since January and July 2022, respectively. The activity coordinator, hired in January 2014, lacked documentation of abuse/neglect/exploitation training since May 2016, resident rights training since June 2017, and infection control and prevention training since December 2018. Interviews with the Human Resource Director and the Interim Director of Nursing revealed a lack of clarity and oversight regarding the facility's orientation and in-service education policies. The Human Resource Director was unsure about the policies and relied on reminders from Relias, a training platform, to notify staff and supervisors of overdue training. The Interim Director of Nursing, who had been in the position for two months, acknowledged the risk of staff not receiving training, which could lead to problems for residents. The facility's policy on elder abuse prevention emphasized the necessity of onboarding and annual education for all team members to understand their roles in abuse prevention, management, and reporting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
NA Training and Dementia Education Deficiency: The facility failed to ensure an NA received the required 12 hours of annual education and dementia management training as required by the Facility Assessment. Records showed the NA had only 10.15 hours of continuing education, no documented dementia training, and did not attend staff in-services or nursing meetings; the FA and DON confirmed the missing training documentation.
The facility failed to ensure that three nurse aides completed the required annual education. Review of employee education files showed no documented evidence that Nurse Aides 10, 11, and 12 completed the required 12 hours of annual training, and the DON confirmed the missing documentation during interview.
Nurse aide training records showed two employees did not receive the required annual in-service education, and both lacked abuse prevention training. The facility’s job description required at least 12 hours of continuing education, and the DON stated she expected nurse aides to complete that amount each year and include abuse prevention training.
Missing Annual In-Service Training Documentation for Nurse Aides: The facility failed to verify that two CNAs had completed the required 12 hours of annual in-service training. Personnel files for both aides lacked documentation, and the DON stated the facility could not determine whether the training had been completed. The facility policy required at least 12 hours of annual in-service training based on employment date, with documentation kept in the personnel file.
Missing CNA Annual and Dementia Care Training: The facility failed to document required annual training for three CNAs and failed to document training in the care of cognitively impaired residents for three other CNAs. Staff record review showed the affected CNAs had no evidence of the required training, and the Administrator verified the missing documentation during interview.
The facility failed to maintain required CNA in-service education for a CNA specific to the resident population. Record review and an interview with the Administrative Nurse confirmed the CNA had not completed mandatory training in psychosocial needs of the older adult, abuse prevention in persons with dementia, and challenging behaviors/care interventions for individuals experiencing dementia. The facility did not provide a CNA education policy.
NA Training and Dementia Education Deficiency
Penalty
Summary
The facility failed to ensure that Nurse Aides (NAs) received at least 12 hours of yearly education and failed to follow its Facility Assessment, which required dementia management training for NAs. Record review of the Facility Assessment showed that staff training, education, and competencies were to include no less than 12 hours per year for NAs and dementia management training among other subjects. The deficiency affected 1 of 1 NAs sampled in a facility with a census of 27. Record review of the Training Hours document for NA-A showed that the NA, hired on 6/11/2024, had only 10.15 hours of continuing education documented from 6/11/2025 to 6/11/2026, and no dementia management training was listed. Nursing services monthly meeting records showed that NA-A did not attend and had no further education through nurse staff meetings. The Facility Administrator stated that past nursing in-services were reviewed and NA-A did not attend any staff in-services, and the Director of Nursing confirmed that the total continuing education hours were not equal to or greater than 12 hours and that no dementia management training was documented.
Failure to Document Required Annual Nurse Aide Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required annual education for three of three nurse aides reviewed, identified as Nurse Aides 10, 11, and 12. Review of the facility's policy on continuing education, dated May 29, 2026, showed that compliance with the facility's standards, policies, and procedures was a condition of employment, including compliance with the facility's training program policies and procedures. Review of the employee education files for Nurse Aides 10, 11, and 12 showed no documented evidence that each had completed the required 12 hours of education between 2025 and 2026. The Director of Nursing confirmed during interview on July 29, 2026, at 10:34 a.m. that there was no documented evidence that these three nurse aides completed the required annual training.
Nurse Aide Annual Training Deficiencies
Penalty
Summary
The facility failed to ensure required in-service training for nurse aides sufficient to maintain continuing competence of at least 12 hours per year and failed to include resident abuse prevention training for two of five nurse aide files reviewed. Review of the facility’s job description for Nursing Assistant, last revised November 23, 2020, stated that nurse aides must attend a minimum of 12 hours of continuing education programs provided by the center to maintain certification. Employee 10’s annual education record showed only 2.38 hours of annual education and no abuse prevention training, and Employee 11’s annual education record also showed no abuse prevention training. During an interview, the DON stated she would expect nurse aides to complete at least 12 hours of required in-service training per year and include resident abuse prevention training.
Missing Annual In-Service Training Documentation for Nurse Aides
Penalty
Summary
The facility failed to ensure nurse aides received the required 12 hours of annual in-service training. Review of employee records showed that CNA M, hired on 08/28/2014, had no evidence of the required 12-hour in-service in the personnel file, and the facility could not provide documentation when requested. CNA N, hired on 06/28/2023, also had no evidence of the required 12-hour in-service in the file, and the facility was unable to provide documentation for that employee as well. During interviews on 07/22/2026, Administrative Nurse D stated the facility could not determine whether CNA M and CNA N had completed any of the required 12 in-service hours. Administrative Nurse D also stated the facility had recently been bought and had new owners, that the personnel files had been located but did not contain documentation of the in-service hours, and that the online training program did not show any documented in-service training hours for either employee. The facility policy stated nurse aides would receive at least 12 hours of in-service training annually based on employment date, with documentation maintained in the personnel file.
Missing CNA Annual and Dementia Care Training
Penalty
Summary
The facility failed to ensure required annual training was completed for three CNAs (#242, #221, and #413) and failed to ensure additional training in the care of cognitively impaired residents was completed for three CNAs (#239, #414, and #277). Review of staff records showed CNA #242, hired 01/30/13, had no documentation of annual training completed; CNA #221, hired 05/24/24, had no documentation of annual training completed; and CNA #413, hired 08/25/23, had no documentation of annual training completed. Staff record review also showed CNA #239, hired 10/31/25, CNA #414, hired 04/24/26, and CNA #277, hired 08/20/25, had no documentation of training for the care of the cognitively impaired. During an interview on 07/20/26 at 2:45 P.M., the Administrator verified there was no documented annual training for CNAs #242, #221, and #413 and no documented training for the care of the cognitively impaired for CNAs #239, #414, and #277.
CNA In-Service Training Not Completed
Penalty
Summary
The facility failed to maintain an in-service training program for Certified Nurse Aide (CNA) M that was specific to the needs of the resident population. Record review showed CNA M did not complete required education in Psychosocial Needs of the Older Adult, Abuse Prevention in Persons with Dementia, and Challenging Behaviors: Care and Interventions for Individuals Experiencing Dementia by the scheduled completion dates. On 07/14/2026 at 11:30 AM, Administrative Nurse D verified that CNA M had not completed these mandatory CNA trainings. Administrative Nurse D stated the education was due at the end of the month they were assigned. Upon request, the facility did not provide a CNA Education Policy.
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