Inadequate Training for Agency Staff Leads to Resident Restraint
Summary
The facility failed to include all staff, particularly agency staff, in their behavioral health care training program, which led to an incident involving a resident with behavioral issues. The facility's policy required training for all employees, including full-time, part-time, and per-diem staff, but explicitly excluded agency staff from this requirement. This lack of training was evident when an agency Certified Nurse Aide (CNA) was not equipped to handle a resident's behaviors appropriately. The CNA restrained the resident by holding their arms and preventing them from leaving their room, which was against the facility's behavioral management protocols. The resident involved had a history of physical and verbal behaviors, rejection of care, and wandering, as documented in their care plan. The care plan included interventions such as observing for signs of agitation, redirecting the resident, and consulting psychiatry or psychology as needed. However, the agency CNA was not trained in these interventions or the facility's specific behavioral crisis intervention training, known as Mandt training. This training was provided to regular staff but not to agency staff, as confirmed by interviews with the facility's staff educator and nursing leadership. The incident was reported when other CNAs heard the resident yelling for help and observed the agency CNA physically restraining the resident. Despite being instructed to release the resident, the CNA initially did not comply. Interviews with facility staff revealed that agency staff were not given the same training as regular employees due to time and resource constraints. The Director of Nursing and the Administrator acknowledged that agency staff were not included in the Mandt training, which is crucial for managing residents with behavioral issues. This oversight in training contributed to the inappropriate handling of the resident by the agency CNA.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. Certified Nursing Assistant # 1 was immediately terminated on 01/12/2025. 2. All behavioral residents have the potential to be affected by this deficient act. The Director of Nursing will audit all agency staff who provide cares to behavioral patients to ensure that agency staff are trained in the appropriate response when behaviors occur. Agency staff will be educated on the definition of code Rainbow responses. The agency education policy was revised to include proper response in the event of a behavior. 3. The Director of Nursing or designee will educate all current and future agency staff on appropriate responses when behaviors occur and during code rainbows. 4. The Director of Nursing or designee will audit all current and future agency workers weekly times 3 months and quarterly thereafter to ensure that they receive appropriate training in proper responses when behaviors occur during code Rainbows. The audit is going to ensure that all agency staff is trained. Findings will be reported to QAPI for further guidance. 5. The Director of Nursing is responsible for this plan of correction. *A code Rainbow is code for a behavior: This alerts the special response team to respond to behaviors.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure that NA-M completed the required Alzheimer's and dementia care training. During record review and interview, the administrator could not locate training documentation for the NA, who had a start date of 9/9/25, and no policy related to the training was provided.
Missing Behavioral Health Training for Staff Member: The facility failed to ensure an employee completed required behavioral health training. Training records showed no evidence the employee completed the course, and interviews confirmed the employee had not finished assigned computerized training. HR and department leadership stated they were responsible for monitoring completion, but both were newly appointed or in training, and the requested annual training policy was not provided.
A facility failed to ensure that 1 of 8 sampled staff members completed the required annual Alzheimer's Disease and Related Disorders training. Review of the training records showed that an NA had not completed the annual Alzheimer's and dementia training, and the administrator confirmed the omission during interview, stating the training is usually assigned through the facility's online program.
Missing Behavioral Health Training for Direct Care Staff: The facility failed to provide required behavioral health training for an LPN and three CNAs whose personnel files were reviewed. Records showed no evidence of the required training, and the HR Coordinator acknowledged the facility could not produce documentation that the staff had completed behavioral health training. The Administrator was later informed of the findings but could not provide evidence to dispute the deficiency.
The facility failed to develop, implement, and maintain an effective behavioral health training program for staff. Review of annual and new hire training showed no behavioral health care training, and the Regional RN verified that no behavioral training program was in place. The Administrator stated the facility cared for many residents with behavioral concerns.
Missing Behavioral Health Training Documentation: The facility failed to document initial or annual Behavioral Health training for 15 of 20 sampled employees, including the DON, AD, SW, Dietary Manager, CNAs, RN, LPNs, and the Infection Preventionist. Personnel records lacked evidence of training upon hire or annually, and the BOM confirmed the missing documentation while stating orientation and annual training were expected under facility policy.
Failure to Document Required Alzheimer's and Dementia Care Training
Penalty
Summary
The facility failed to ensure that 1 of 8 staff members, NA-M, had completed the required Alzheimer's and dementia care training program. During the survey, a request was made for Alzheimer's and/or dementia care training records for eight employees, and the administrator later stated that training could not be found for NA-M, whose start date was 9/9/25. The administrator stated it was the expectation that all staff receive Alzheimer's and/or dementia care training before working with residents and that documentation of the training be maintained. A policy related to Alzheimer's and dementia care training was requested, but none was provided.
Missing Behavioral Health Training for Staff Member
Penalty
Summary
The facility failed to provide required behavioral health training for 1 of 23 sampled staff members, PT F. Review of the facility’s training log showed no evidence that PT F completed behavioral health training, and the personnel record showed a hire date of 01/31/2025. Review of the training log for the previous 12 months also showed no evidence of behavioral health training for PT F. During interviews, the HR D stated she was newly appointed and was still being trained on her duties and did not have access to view or run reports in the computerized training system. CHR E stated annual required training was computer generated quarterly and staff were emailed regarding required completion and delinquent courses, and that HR and department heads were responsible for monitoring completion and reporting delinquent staff. The Administrator stated HR was responsible for reporting staff completion of annual computerized training, but PT F had not completed assigned behavioral health training and he was unable to provide the required training because the assigned training had not been completed. A requested policy regarding annual employee training was not provided prior to exit.
Failure to Complete Required Annual Dementia Training
Penalty
Summary
The facility failed to ensure that 1 of 8 sampled staff members reviewed for annual required Alzheimer's Disease and Related Disorders training had completed the training. Review of the requested annual Alzheimer's and dementia training on 8/30/26 identified that nursing assistant (NA)-E had not completed the required annual training. During an interview on 8/30/26 at 1:30 p.m., the administrator confirmed that NA-E had failed to complete the annual training and stated that the facility typically assigns the training through its online training program, but he had not realized NA-E had not completed the required training. A policy was requested, but none was provided by the end of the survey period.
Missing Behavioral Health Training for Direct Care Staff
Penalty
Summary
The facility failed to provide required behavioral health training for 4 of 5 sampled direct care staff members whose personnel files were reviewed for training requirements. Review of the personnel files for an LPN, three CNAs, and another CNA showed no evidence that behavioral health training had been completed, despite their hire dates being documented in the files. The staff members identified were hired on 04/27/2026, 05/19/2026, 03/19/2026, and 11/16/2023, and the records reviewed did not contain the required training documentation. On 07/20/2026 and again on 07/22/2026, the HR Coordinator was asked to provide the behavioral health training records for the identified staff, but no evidence was produced. During interviews on 07/22/2026, the HR Coordinator stated she was responsible for staff training and ensuring staff received the correct training as required, but also acknowledged the facility could not provide evidence that the staff had received behavioral health training. On 07/23/2026, the Administrator was informed of the findings and could not present documented evidence to dispute the deficient practice.
Lack of Behavioral Health Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program related to behavioral health care and services for 1 of 1 staff training programs reviewed. Review of the facility’s annual and new hire staff training showed no behavioral health care training. Staff 4, the Regional RN, verified on 7/15/26 at 12:30 PM that the facility did not have a behavioral training program in place. Staff 1, the Administrator, stated on 7/15/26 at 12:33 PM that the facility cared for a large number of residents with behavioral concerns.
Missing Behavioral Health Training Documentation
Penalty
Summary
Behavioral Health training was not completed timely for 15 of 20 sampled employees, based on interview, personnel record review, and document review. The facility failed to ensure initial training was documented for Employee #1, #12, #13, #14, #15, #16, and #17, and failed to ensure annual training was documented for Employee #2, #3, #5, #6, #7, #8, #9, and #10. The affected employees included the Administrator, DON, Activities Director, Social Worker, Dietary Manager, CNAs, Infection Preventionist, RN, and LPNs. The personnel records reviewed lacked documented evidence of Behavioral Health training completed upon hire or annually, depending on the employee. On 06/29/2026 at 8:43 AM, the BOM stated there was orientation training upon hire and annual training thereafter, and that agency staff do not go directly through the facility for orientation training. The BOM confirmed that the listed employees' records did not contain documentation showing Behavioral Health training was completed upon hire and annually, and the facility policy titled, Nursing Personnel Education and Training, published 11/2016, stated that education for new employees and contract staff as part of orientation and scheduled annually includes Behavioral Health training.
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