Lack of Orientation for Agency Nurses
Summary
The facility failed to provide adequate orientation and training to agency nurses, which is a requirement for individuals providing services under a contractual agreement. Three registered nurses (RN-A, RN-B, and RN-C) who worked at the facility through an agency reported that they did not receive any orientation to the facility or its policies and procedures. These nurses also mentioned that they were often the only nurse on duty during their shifts, which could potentially impact the quality of care provided to the 36 residents of the facility. The Director of Nursing (DON) and the facility administrator acknowledged the lack of a structured orientation process for agency staff. The DON was unsure if there was a specific process in place, while the administrator admitted that agency staff should receive orientation, a review of policies, and a tour on their first shift. However, the administrator was unable to provide evidence of such orientation for the agency nurses. The facility's orientation policy, dated 2023, mandates that all staff, including those under contractual agreements, must complete general orientation before having formal contact with residents, and documentation of this process should be maintained in personnel files. Despite requests, no evidence of orientation for agency staff was provided.
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 with an intellectual disability received continuous care from several Developmental Disability Caregivers (DDCs) who were present at the bedside over multiple shifts. Facility records later showed the resident was found with arms tied to bed rails, and leadership informed a DDC that restraints were not allowed. The DON reported that the DDCs were expected to provide services such as feeding, redirection, and companionship, but confirmed that none of the DDCs received training on facility policies or expectations, including restraint use, and that she had only assumed their outside employer provided equivalent training.
Surveyors found that the facility did not maintain an effective emergency preparedness training program for multiple existing staff members. The facility’s own assessment stated that staffing would be adjusted based on staff education to protect resident health and safety, yet records showed no evidence that several long‑term and more recently hired staff had completed required emergency preparedness training. In an interview, the DON could not produce documentation of this training and acknowledged that it was her expectation that these staff would have received it.
The facility failed to ensure required training was completed and documented for most staff, including annual abuse identification/prevention/reporting, dementia management, resident rights, QAPI, effective communication for all direct care staff, infection control, compliance and ethics, and behavioral health. Record review showed large numbers of staff without evidence of completion, missing sign-in sheets for in-services, and training modules without documentation of use. In interviews, the NHA reported that most training, including abuse and dementia, had been completed and described onboarding and lunch-and-learn processes, but could not locate records to verify staff participation. The regional nurse consultant acknowledged that the existing training plan was not effective in ensuring staff received all required education.
Facility staff did not maintain an effective training program for all personnel. Orientation materials lacked behavioral health content based on the facility assessment, and the infection control module omitted the facility’s own infection prevention and control policies and procedures. Multiple GNAs, an LPN, and a laundry aide were not current with required computer-based trainings, including abuse, Resident Rights, and infection control. Corporate assigned annual CBT modules, but there was no system in place at the facility level to ensure staff completed the required education, and leadership could not provide a rationale for these deficiencies.
A newly hired RN, who had not completed orientation and had never transferred a resident to a hospital before, was responsible for two resident transfers during one shift, including a resident who became unresponsive and required emergent EMS transport. The RN reported she was still being trained on the hospital transfer process, including required paperwork and steps, and was left to continue paperwork while the assisting RN went to eat. 911 and EMS records showed an abandoned 911 call from the facility, a return call where staff reported no emergency, and subsequent involvement of the local ED and ambulance service before EMS was dispatched for a reported cardiac arrest. EMS found the resident unconscious, hypoxic, and minimally responsive, and hospital records documented severe clinical instability on arrival. The DON and NHA stated new nurses receive five days of training and an orientation checklist covering emergency procedures and rapid transport, but the DON acknowledged the checklist does not have to be completed before return, had not been turned in for this RN, and she did not know which training items were finished, demonstrating a failure to ensure and monitor effective training for new nursing staff.
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.
Failure to Train Developmental Disability Caregivers on Facility Policies
Penalty
Summary
The facility failed to implement an effective training program for Developmental Disability Caregivers (DDCs) who provided care to a resident with unspecified intellectual disabilities. The resident was admitted with a diagnosis that limited intelligence and disrupted abilities necessary for independent living, and the facility’s records showed that DDCs were present at the bedside throughout the night and early morning. Progress notes documented that DDC staff were with the resident at multiple times, but did not specify which DDC was present at each time. Later documentation indicated that the DON and ADON observed the resident with his arms tied to the bed rails, and the ADON then informed one of the DDCs that restraints were not allowed in the facility. Interviews with the DON and ADON revealed that three DDCs rotated in providing continuous care to the resident, relieving one another over the course of the resident’s stay. The DON stated that the DDCs were expected to provide the same services they had provided in the resident’s home, such as feeding, redirection, and companionship. However, the DON confirmed that none of the three DDCs received any training from the facility regarding its policies and expectations before assisting the resident. She further stated that she assumed the DDCs’ employer required the same training as the facility required for its own staff and was unsure what training the DDCs had actually received. The facility did not provide any training to these DDCs on its policies, including those related to the use of restraints, prior to their involvement in the resident’s care.
Failure to Provide Required Emergency Preparedness Training for Existing Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective emergency preparedness training program for existing staff, as required by its facility assessment. The facility assessment, last revised on 2/5/2026, stated that staffing would be adjusted based on staff education to ensure residents’ health and safety were maintained. Record review showed no evidence that four staff members—Staff H (hired 3/19/2015), Staff I (hired 10/11/2022), Staff J (hired 5/4/2021), and Staff K (hired 11/7/2024)—had completed emergency preparedness training. During an interview on 2/11/2026 at approximately 2:00 PM, the Director of Nursing Services (Staff M) was unable to provide documentation of emergency preparedness training for these staff and stated it was her expectation that such training would have been completed for them. This deficiency was identified as having the potential to impact all 163 residents in the facility, as well as an indeterminable number of staff and visitors, due to the lack of documented emergency preparedness education for these staff members.
Widespread Failure to Complete and Document Required Staff Training
Penalty
Summary
The facility failed to provide, implement, and maintain an effective training program for new and existing staff as required by its own In-Service Training policy. The policy, revised in April 2021, required all staff to participate in initial orientation and annual in-service training on topics including effective communication, resident rights, abuse prevention and reporting, QAPI, infection prevention, behavioral health, and compliance and ethics. Record review showed that 75 of 83 staff did not receive the required annual abuse identification, prevention, and reporting training; 39 of 83 staff did not complete dementia management training; 31 of 83 staff did not complete resident rights training; 30 of 83 staff did not complete QAPI training; 49 of 49 direct care staff did not complete effective communication training; 20 of 83 staff did not complete infection control training; 16 of 83 staff did not complete compliance and ethics training; and 13 of 49 direct care staff did not complete behavioral health training. Further review of training records revealed missing or incomplete documentation for several required topics. For dementia training, 39 staff lacked documentation of completion and no alternative in-service records were provided. For resident rights, the facility produced an in-service training document but no sign-in sheet to verify attendance. For QAPI, an in-service document and sign-in sheet were provided, but 30 staff still lacked evidence of completion. No direct care staff had documented completion of effective communication training, and although a copy of the training content existed, there was no proof it had been used. Infection prevention records showed some staff completed online and in-service training, but 20 staff still lacked required training. Compliance and ethics training records listed all staff on an online roster, but many had no completion dates and no documentation of use was provided. Behavioral health training records showed 13 staff without required online training and no in-service documentation. In interviews, the NHA reported that most training was done during onboarding, stated that about 91% of trainings were completed, and claimed all abuse and dementia trainings were finished, but she could not produce records to support these statements, and acknowledged that some training sessions such as lunch-and-learns were not documented. The regional nurse consultant stated the current training plan was not effective to ensure all staff were sufficiently trained as required.
Failure to Maintain Effective Staff Training Program and Ensure Completion of Required Education
Penalty
Summary
Facility staff failed to develop and implement an effective training program for new and existing staff, contracted staff, and volunteers, as required by regulation and based on the facility assessment. Review of the facility’s orientation PowerPoint on 1/22/26 showed that behavioral health topics were not included, despite the requirement that such topics be based on the behavioral health needs identified in the facility assessment for the resident population. Although the list of computer-based training modules included required topics such as effective communication, Resident Rights, Elder Abuse, QAPI, Infection Control, Compliance and Ethics, and Behavioral Health, the infection control module did not include the facility’s own infection prevention and control policies and procedures. During interview, the NHA reported she did not have a copy of the previous NHA’s facility assessment and had not completed a new assessment since returning to the position in 8/2025, resulting in training topics not being aligned with the facility’s assessed needs. Review of individual staff computer-based training transcripts on 1/22/26 showed multiple staff members were not current with required trainings. One GNA had completed only four computerized training modules in 2024, with abuse being the only required topic listed, and had no completed trainings between 2021 and those 2024 modules. An LPN had last completed computerized training modules in 2022, and two other GNAs had not completed computerized training modules since 2024. A laundry aide had not completed Resident Rights training since 2023 and had not completed infection control training that included the facility’s policies and procedures. The Corporate Clinical Resource Nurse, who had served as interim DON and was acting as Nurse Practice Educator, stated that corporate determined and assigned annual computer-based training topics, but the facility had no system to ensure staff actually completed the assigned modules. When these concerns were reviewed with the NHA, she offered no rationale for the deficient practice.
Failure to Ensure Effective Orientation and Emergency Transfer Training for Newly Hired RN
Penalty
Summary
The deficiency involves the facility’s failure to provide and monitor an effective training program for a newly hired RN, specifically related to emergency procedures and hospital transfers, which contributed to a delayed response to a resident’s acute change in condition and emergent transfer. The facility’s DON and NHA stated that new nurses receive five days of training and an orientation checklist that includes emergency procedures, hospitalization, transfer forms, and emergency access for rapid transport. However, the DON acknowledged that the checklist does not have to be completed before being returned and that the orientation checklist for the involved RN had not been turned in, leaving the DON unaware of which training items had been completed. The orientation checklist for this RN was not provided to surveyors by the time of exit. The newly hired RN reported that she started at the end of the prior month and had not completed all of her training, including training on transferring a resident to an acute care hospital. On the night in question, she had to transfer two residents to the hospital for changes in condition and stated she had never done this before. She reported that another RN was assisting her with the orientation training checklist and with completing the paperwork, steps, and packet required for a hospital transfer. The assisting RN confirmed that the new RN appeared overwhelmed and unfamiliar with the transfer process and that she tried to help with the required paperwork. The new RN stated that she asked whether they should just call 911 for the resident and was told by the assisting RN to finish the paperwork while the assisting RN went to eat and would help again afterward. During this same shift, EMS and 911 records show multiple calls associated with the facility and a delay in EMS activation for the resident who was ultimately found unresponsive. 911 records documented an abandoned call from the facility, a return call from 911 during which facility staff reported no emergency, and subsequent calls from the local emergency department and ambulance service indicating that the hospital had received report on a patient from the facility but had not yet received the patient. EMS documentation for the resident later transported described dispatch for a cardiac or respiratory arrest, arrival to find the resident unconscious, minimally responsive, hypoxic, and requiring escalating oxygen support and eventual transfer to the emergency department. Hospital records documented that the resident, an older adult with dementia with psychotic features, major depressive disorder, and atrial fibrillation on Eliquis, was brought in unresponsive, hypotensive, tachycardic, cool, and cyanotic, and was intubated for airway protection. The combination of incomplete orientation, lack of verified competency in emergency transfer procedures, and the facility’s failure to ensure the new RN was effectively trained and monitored in these processes led to a delay in treatment and emergent hospital transfer for this resident. The DON confirmed that she did not know which emergency procedure and transfer-related training items the new RN had completed because the orientation checklist had not been returned. The Licensed Nurse Orientation and Skill Check form included items such as emergency procedures, hospitalization, transfer form from the electronic record, and emergency access for rapid transport, but there was no evidence these competencies had been completed or validated for the new RN. The new RN’s own statements that she had never transferred a resident to the hospital before, had not yet completed all of her training, and did not complete the first transfer’s paperwork correctly further demonstrate that the facility did not maintain an effective training and monitoring process for new nurses in critical emergency and transfer procedures, contributing to the deficient practice identified by surveyors.
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