Failure to Train Staff on Abuse Prevention Leads to Resident Altercation
Summary
The facility failed to adhere to its abuse policy by not ensuring that all staff were trained and knowledgeable on how to handle resident-to-resident altercations. This deficiency was highlighted by an incident involving two residents, R1 and R2, who were left alone during an altercation. R1, a male with intact cognition, and R2, a male with severe cognitive impairment, engaged in a loud argument in the dining room. A housekeeping aide, V9, who was present, became nervous and left the residents unattended to find nursing staff, resulting in a flipped dining room table. The aide admitted to not receiving any abuse training since starting work five months prior. Interviews with other staff members, including licensed practical nurses and a housekeeping supervisor, revealed a lack of consistent abuse training. Some staff members had not received any abuse training since their employment began, while others relied on previous training from different roles. The Director of Nursing confirmed that all new staff should be trained on abuse prevention and response, but the facility's policy was not effectively implemented. The facility's abuse prevention program outlined the need for orientation and annual training, but this was not consistently followed, leading to the incident involving R1 and R2.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to train agency staff on abuse prohibition, resident abuse prevention, and how to identify and report abuse, neglect, exploitation, and misappropriation of resident property. An LPN working at the medication cart stated the facility had not provided this training, and review of personnel records showed the same gap for another LPN, an RN, and a nurse aide. The NHA confirmed agency staff had not received the required education on the facility’s abuse policies and procedures.
Missing Required Abuse Training for Multiple Staff: The facility failed to ensure required DAA training was completed for 3 of 9 staff reviewed. A CNA hired in the facility had no record of completing DAA training within 6 months of hire, and two other staff members had no documentation of the required 3-year renewal training. The HR Director confirmed the missing training, and the Administrator stated DAA training should be completed within 6 months of hire and renewed every 3 years.
Failure to verify abuse and neglect training for an agency CNA. Record review showed CNA A’s file contained an expired Abuse Assessment and no current documentation of abuse, neglect, or exploitation training before he provided resident care. The staffing agency account manager could not locate proof of current training, and the ADM, HR, and DON stated they were responsible for verifying training before staff worked with residents. The facility policy required continuous education on abuse prohibition for all new and current employees, including volunteers.
Missing Required Abuse and Dementia Training for Staff: The facility failed to ensure that two staff members, including a dietary server and an ST, had documented annual training on abuse, neglect, and exploitation. Surveyors found that the staff transcripts did not show completion of required topics, while the DON stated that staff are expected to complete annual modules covering abuse, resident rights, infection control, emergency preparedness, and dementia care. The HRD stated that the dietary server was not required to have abuse and infection control training, and the ST’s transcript did not list several orientation topics the ST said she had completed.
A facility failed to provide required dependent adult abuse training within 6 months of hire for an RN. Record review showed the RN completed the 2-hour mandatory reporter training after the policy deadline, and the Director of Compliance acknowledged the training was late and said the facility had recently changed its process for enrolling new hires in the class right away.
Failure to provide required abuse, neglect, and exploitation training was identified for an NA. Facility policy required annual training covering abuse, neglect, exploitation, misappropriation of resident property, reporting procedures, dementia management, and resident abuse prevention. The NA's personnel file did not show the required annual in-service training, and HR confirmed the training had not been provided.
Failure to Train Agency Staff on Abuse Prohibition and Reporting Procedures
Penalty
Summary
The facility failed to provide training to agency staff on the facility’s procedures related to abuse, neglect, exploitation, misappropriation of resident property, and resident abuse prevention for four of six employees reviewed. During an observation on the third floor, an LPN employed by a nurse staffing agency was working at the medication cart and stated that the facility had not provided training on the abuse prohibition policy or on how to identify and report abuse, neglect, exploitation, or misappropriation of resident property. There was no documentation that this employee had been trained on the facility’s abuse prohibition policies and procedures during orientation and staff development. Review of three additional nurse staffing agency personnel records showed the same lack of education and training for another LPN, an RN, and a nurse aide. The records did not show that these agency employees received training on the facility’s abuse prohibition policy and procedures, including how to identify and report abuse, neglect, exploitation, or misappropriation of resident property, or on resident abuse prevention. During an interview, the Nursing Home Administrator confirmed that agency staff had not been provided training on the prohibition of all forms of abuse, neglect, and exploitation or on the facility’s specific abuse prohibition policies and procedures.
Missing Required Abuse Training for Multiple Staff
Penalty
Summary
The facility failed to ensure staff completed required Dependent Adult Abuse (DAA) training within 6 months of hire and failed to ensure renewal training was completed within 3 years for 3 of 9 staff reviewed: Staff C, a CNA; Staff D, a CNA; and Staff E, a cook. Staff C’s employee file documented a hire date of 3/27/25, but no DAA certificate showing training completed within 6 months of hire was found. Staff D’s file showed DAA training completed on 5/16/23, but there was no documentation of the required renewal training within 3 years. Staff E’s file showed DAA training completed on 10/22/22, but there was no documentation of the required renewal training within 3 years. During interviews, the HR Director stated Staff C had not completed DAA training, Staff D had not completed the 3-year renewal, and Staff E never completed the correct renewal DAA training. The Administrator stated DAA should be completed within 6 months of hire and renewed every 3 years. Review of the undated Abuse Prevention Program policy showed the facility required abuse prevention, identification, and reporting training for new hires and existing staff as required by CMS.
Failure to Verify Abuse and Neglect Training for Agency CNA
Penalty
Summary
The facility failed to provide required training to staff on abuse, neglect, exploitation, and misappropriation of resident property, and failed to verify that CNA A had current training before allowing him to provide resident care. Record review showed CNA A was employed through a staffing agency, his first day providing care at the facility was [DATE], and his employee file contained an Abuse Assessment that had expired on [DATE] with no documentation of current training related to abuse, neglect, and exploitation. The staffing agency’s blank Abuse Neglect and Misappropriation Assessment form also contained no evidence of education material attached to it. During interviews, CNA A stated he had worked his first shift at the facility on [DATE] and had not worked there since, and he stated his trainings were current, including abuse and neglect. The staffing agency account manager stated she was unable to locate documentation showing CNA A had completed current Abuse, Neglect, and Exploitation training. The ADM, HR, and DON each stated they were responsible for verifying staff training before staff cared for residents, and the HR stated the required training verification had been missed because CNA A accepted the shift at the last minute. The facility policy titled Abuse, Neglect and Exploitation or Mistreatment stated that all new and current employees, including volunteers, receive continuous education training and reinforcement identifying all aspects of abuse prohibition, and that abuse and neglect education is provided and required by regulatory agencies.
Missing Required Abuse and Dementia Training for Staff
Penalty
Summary
The facility failed to ensure that two staff members received annual training on abuse, neglect, and exploitation. On 5/28/2026, surveyors requested training records for a Dietary Server and a Speech Therapist. The Dietary Server’s 2025 transcript did not list abuse, neglect, and exploitation training, and the record did not show when that annual training was completed. The Speech Therapist’s 2026 transcript also did not list abuse, neglect, and exploitation training, and the record did not show when that training was completed. During an interview, the DON stated that staff receive annual module training through eCampus and additional topics during weekly meetings, including abuse, resident rights, infection control, emergency preparedness, and dementia care. She stated that the therapy team and dietary staff take the same training as nursing staff and that she expects staff to complete their required modules. The Administrator stated that therapy employee files were not kept on site and would need to be obtained through the therapy company. The Speech Therapist stated that she had received orientation training by video and believed there should be a transcript showing completion of abuse training, infection control, Elder Justice Act, emergency preparedness, and resident rights training. However, her transcript did not list those topics, and it showed modules on other subjects beginning later in the spring. The HR Director stated that the Dietary Server was not required to have abuse and infection control training, and also stated that the contracted rehabilitation company should provide its employees the same training as the facility provides. The facility policy stated that all new and existing staff, volunteers, and contractors will receive training on resident rights, abuse, neglect and exploitation, dementia management, and infection control.
Late Dependent Adult Abuse Training for New RN
Penalty
Summary
The facility failed to provide dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed. Personnel file review showed Staff F, an RN hired on 8/5/25, completed the 2-hour dependent adult abuse mandatory reporter training on 3/24/26, which was later than the facility policy requirement. The facility policy titled Abuse Prevention, Identification, Investigation and Reporting Policy, reviewed 07/2025, stated each employee must complete 2 hours of training related to identification and reporting dependent adult abuse within six months of initial employment. During interview on 5/20/26 at 10:00 AM, the Director of Compliance acknowledged the training was completed late and stated the facility had recently changed its process so new hires would be enrolled in the DAA class right away instead of waiting 4-6 months.
Failure to Provide Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide annual in-service training on Abuse, Neglect, and Exploitation for one of three staff members, Nurse Aid (NA) Employee E3. Review of the facility's policy on Continuing Education showed that compliance with facility standards, policies, procedures, and the training program is a condition of employment. Review of the Training Requirements- Abuse, Neglect and Exploitation Training policy showed the facility will include activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, along with procedures for reporting incidents of abuse, neglect, exploitation, misappropriation of resident property, dementia management, and resident abuse prevention. Review of NA Employee E3's personnel record showed a hire date of 4/5/24, and the file did not contain annual in-service training on Abuse, Neglect, and Exploitation for the period 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed the facility failed to provide this training for NA Employee E3.
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