Failure to Implement Behavioral Health Training Program
Summary
The facility failed to implement and maintain an effective training program for its staff, specifically in the area of behavioral health care and services. This deficiency was identified during a review of employee training records and interviews with facility staff. The facility's assessment, dated August 1, 2024, indicated that there are over 40 residents with behavioral symptoms residing in the facility on a daily basis, necessitating behavioral health services. Despite this need, the review of training records for 24 direct care staff members working on specific dates in January 2025 showed no evidence of completed behavioral or mental health training. The Director of Nursing (DON) acknowledged during an interview that the facility had been without a Staff Development Coordinator (SDC) since September 2024, which contributed to the lack of training. The DON stated that the SDC was responsible for providing staff with the necessary training on behavioral health. The absence of the SDC resulted in the training not being completed. The Administrator confirmed that if the training was not documented in the records provided to the surveyors, it had not occurred.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not provide required behavioral health training to all staff, including contract housekeeping, dietary, maintenance, and several CNAs, as outlined in its facility assessment. Training records and interviews confirmed that behavioral health education was not included in new hire orientation or annual in-services for non-nursing staff, potentially affecting all residents.
The facility did not ensure that staff, including LPNs, CNAs, administrative, dietary, and activity personnel, received behavioral health training as required, despite having numerous residents with psychiatric or mood disorders who needed such care. Personnel files and staff interviews confirmed the lack of training documentation for these staff members.
The facility failed to provide adequate behavioral health training for staff, necessary for caring for residents with mental and psychosocial disorders, including trauma and PTSD. Only one in-service session on de-escalation tips was conducted in the past year, which did not meet regulatory requirements. Several staff members did not receive any behavioral health training during orientation, and there were four self-reported incidents involving staff-to-resident interactions in the past six months. Staff expressed concerns about safety due to insufficient training.
The facility did not provide required behavioral health training to staff during orientation or annually, despite accepting residents with psychiatric disorders. Personnel files for various staff, including a dietary aide, housekeeper, LPN, and CNAs, showed no evidence of such training. An interview with the Administrator confirmed the lack of documentation for behavior training, although an in-service was scheduled for later.
The facility failed to provide documented mental and behavioral health training for three STNAs, affecting the care of all 44 residents in a 45-bed secured facility specializing in mental health. This deficiency was confirmed through employee file reviews and an HR interview, revealing a gap in compliance with the facility's training requirements.
The facility did not provide required behavioral health training to newly hired STNAs, as confirmed by personnel file reviews and an HRD interview. The facility specializes in mental health behaviors, making this training essential.
Failure to Provide Behavioral Health Training to All Staff
Penalty
Summary
The facility failed to provide behavioral health training to all staff as required by its own facility assessment and regulatory standards. Review of training records and personnel files showed that behavioral health training was not provided upon hire or annually to several categories of staff, including contract housekeeping, dietary, maintenance, and multiple certified nursing assistants. The facility assessment indicated that all staff would receive education and competency training related to caring for residents with mental and psychosocial disorders, as well as those with trauma histories, but documentation did not support that this training was completed for all employees. Interviews with the Corporate Human Resource Manager and the contracted Regional Housekeeping Director confirmed that behavioral health training was not included in new hire orientation or in the annual in-service requirements for staff. Additionally, a review of a nursing in-service on behaviors revealed that only nursing staff were included, excluding other departments. This deficiency had the potential to affect all 86 residents in the facility, as staff across multiple departments were not adequately trained to address behavioral health needs as outlined in the facility's own assessment.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received behavioral health training as required and as determined by the facility assessment. Personnel file reviews for multiple staff members, including LPNs, CNAs, the Human Resource Manager, the Administrator, a Dietary Aide, and the Activity Director, revealed no evidence of completed behavioral health training. Staff interviews confirmed that these individuals had not received the necessary training. The facility assessment indicated that care for residents with psychiatric or mood disorders was not provided, yet staff interviews revealed that 37 residents with such diagnoses were present and required assistance with behavioral health symptoms. The deficiency was identified through a combination of personnel file reviews, record reviews, and staff interviews. The Director of Nursing confirmed the presence of 37 residents with psychiatric and/or mood diagnoses at the time of the survey. Despite this, there was no documentation or evidence that staff responsible for their care had received behavioral health training, as required by regulations and the facility's own assessment.
Inadequate Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide adequate behavioral health training to its staff, which is necessary for caring for residents with mental and psychosocial disorders, including those with a history of trauma and PTSD. The facility's assessment indicated a need for staff competency in these areas, yet the only training provided in the past year was a single in-service session on de-escalation tips, which did not meet regulatory requirements. This session was attended by 25 employees, seven of whom are no longer employed at the facility. Additionally, a review of employee files revealed that several staff members, including CNAs, LPNs, and administrative personnel, did not receive any behavioral health training during their orientation. The deficiency was further highlighted by the fact that in the past six months, there were four self-reported incidents involving staff-to-resident interactions. Interviews with staff members, including CNAs and the Director of Nursing, confirmed the lack of adequate training, with some staff expressing concerns about their safety due to insufficient behavioral health training. The facility is currently working on establishing a crisis prevention and de-escalation/intervention training program, but as of the time of the report, no such program was in place.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide behavioral health education to all staff during orientation and annually thereafter, as required by their facility assessment. The assessment indicated that the facility accepted residents with psychiatric disorders, including impaired cognition, mental disorders, bipolar disorder, schizophrenia, post-traumatic stress disorder, anxiety disorder, and behaviors requiring interventions. However, a review of personnel files for various staff members, including a dietary aide, housekeeper, LPN, and several CNAs, revealed no evidence of training on mental health behaviors. The deficiency was further confirmed during an interview with the Administrator, who acknowledged the lack of documentation for behavior training provided to staff at orientation or within the previous twelve months. Although an annual in-service for behavioral training was scheduled for December 2024, there was no evidence that such training had been conducted previously. This oversight had the potential to affect all 38 residents residing in the facility, who may have required specialized care due to their psychiatric conditions.
Deficiency in Staff Training on Mental and Behavioral Health
Penalty
Summary
The facility failed to ensure that all staff received the necessary education on mental and behavioral health, as required by their facility assessment. This deficiency was identified through a review of employee files, interviews, and the facility assessment. The facility is a 45-bed secured facility specializing in behaviors and mental health, with a majority of long-term residents. Despite this specialization, the facility did not provide documented evidence of mental and behavioral health training for three State tested Nursing Assistants (STNAs) out of five reviewed. These STNAs, hired between 2015 and 2023, did not have records of receiving the required education, which is crucial for the care and management of the resident population. The lack of documented training for STNAs #505, #504, and #503 was confirmed during an interview with Human Resources. This oversight had the potential to affect all 44 residents residing in the facility, as the entire facility specializes in mental and behavioral health care. The facility's assessment, updated in July 2024, indicated that staff training and competencies are necessary to provide appropriate care and support for the resident population. However, the absence of documented training for these STNAs highlights a significant gap in the facility's compliance with its own training requirements.
Lack of Behavioral Health Training for New STNAs
Penalty
Summary
The facility failed to ensure that newly hired State tested Nurse Aides (STNAs) received the required specialty behavioral training. This deficiency was identified through a review of personnel files and staff interviews. Specifically, the personnel files for two STNAs, hired in August 2024, showed no evidence of training on mental health behaviors. An interview with the Human Resources Director confirmed that the facility did not provide formal specialized training for mental health behaviors to newly hired staff. The facility assessment indicated that the facility specializes in mental health behaviors, highlighting the importance of such training.
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.
