Failure to Provide Required Abuse and Neglect Training
Summary
The facility failed to adhere to its policy and procedure regarding the Abuse, Neglect, Exploitation, and Misappropriation Prevention Program by not providing annual training to a significant portion of its staff. Specifically, 17 out of 73 Certified Nursing Assistants (CNAs), 7 out of 31 Licensed Vocational Nurses (LVNs), 4 out of 12 Dietary Aids (DAs), 2 out of 4 cooks, 2 out of 20 Feeding Assistants (FAs), 1 out of 3 Speech Language Pathologists (SLPs), 1 out of 2 Respiratory Therapists (RTs), 1 out of 6 Restorative Nursing Assistants (RNAs), 2 out of 3 Occupational Therapists (OTs), 1 Minimum Data Set Coordinator (MDSC), and 1 out of 7 Registered Nurses (RNs) did not receive the required training. This lack of training was confirmed during an interview and record review with the Director of Staff Development, who acknowledged that the staff had not attended make-up sessions and no additional documentation was provided. The absence of documented training for these staff members indicates a failure to ensure that they are aware of what constitutes abuse, neglect, and exploitation, as well as the reporting requirements. This deficiency was identified during a review of the facility's annual training records and its policy and procedure document dated April 2021, which mandates staff orientation and training. The failure to provide this essential training had the potential for abuse in residents to go unnoticed and unreported within the facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Several nurses did not receive required training on abuse, neglect, and exploitation during orientation or annually, as mandated by facility policy. Employee file reviews and staff interviews confirmed missing documentation of this training, despite expectations set by facility leadership and policy requirements. This deficiency had the potential to affect all residents in the facility.
A review of personnel files and staff interviews revealed that five CNAs did not receive required training or competency verification in dementia management and abuse prevention, despite facility policies mandating such education. The DON confirmed the absence of training records, and this deficiency had the potential to impact all residents in the facility.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to Nursing Staff
Penalty
Summary
The facility failed to ensure that four nursing staff members received required training on abuse, neglect, and exploitation during orientation and annually, as mandated by facility policy. Employee file reviews showed that three nurses hired within the past two years had no documented evidence of having completed abuse/neglect training within the last 12 months. Additionally, a recently hired nurse had no documentation of receiving this training at all. These findings were confirmed through staff interviews, where the Director of Nursing, Administrator, and Human Resources Director all acknowledged the expectation that staff complete required in-services and that management should monitor compliance. However, the Human Resources Director was unable to explain why the required abuse training was missing for these staff members. The facility's policy on abuse prevention and reporting, updated in 2018, requires all new employees to receive training on abuse policies during orientation and mandates annual training for all staff. The policy specifies that training must cover definitions of abuse, neglect, and exploitation, reporting requirements, and appropriate interventions. The lack of documented training for these four nurses represents non-compliance with both facility policy and regulatory requirements, with the potential to affect all residents in the facility, which had a census of 92 at the time of the review.
Failure to Provide Required Dementia and Abuse Prevention Training to CNAs
Penalty
Summary
The facility failed to provide required training and competency verification in dementia management and abuse prevention for five Certified Nurse Aides (CNAs) as evidenced by a review of their personnel files. The files for these CNAs, who had hire dates ranging from 2011 to 2023, contained no documentation of training or competency in abuse, neglect, exploitation, or dementia care. This lack of documentation was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the necessary training had not been provided as required and that there were no records of such training for the staff in question. Policy review revealed that the facility's own procedures require in-service training for nurse aides in areas including effective communication, dementia management, and abuse prevention, as well as annual education for existing staff on abuse, neglect, and exploitation. Despite these policies, the facility did not ensure that the five CNAs received the mandated education, which had the potential to affect all 91 residents in the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
