Deficiency in CNA Dementia Care Training Documentation
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required hours of training and annual in-services on dementia care management, as mandated by regulations. Specifically, the facility could not provide documentation that three CNAs had completed the necessary training. CNA #23, hired in July 2023, had a last recorded training in November 2024, which did not include dementia care management. CNA #24, hired in March 2019, had their most recent training documented in November 2024, also lacking evidence of dementia care management education. CNA #25, hired in May 2023, had no documentation confirming completion of the required dementia care management education. During an interview, the Assistant Director of Nursing acknowledged the absence of documentation for these CNAs.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified Required in-service training for Nurse Aides must include dementia management training and resident abuse prevention training. Certified Nurse Aides #23, #24, and #25 did not have the required hours of the mandatory training in regards to Dementia training. No residents suffered ill effects. Upon notification of this deficiency, Certified Nurses Aides #23, #24, and #25 were all contacted and provided with Dementia in-service and all now meet the standard for the 12 hours of annual in-service. Audits of the employees assigned residents and units revealed no ill effects to those or any other resident as a result of this deficiency. Residents at Risk: Any resident can be affected by this deficient practice. In-service coordinator/educator conducted an audit of all CNAs to determine if any other CNA was out of compliance with Dementia education or the annual 12 hour education, and none were noted out of compliance. The facility respectfully states that while all staff and therefore residents could have been affected, no other staff or resident was affected. Systemic Changes: All CNAs will receive mandatory training on an annual basis by Nurse Staff Educator/Designee. The Administrator has reviewed the facility’s policy on Employees Annual Mandatory Education and found it to be in compliance with all local, state and federal regulations. Monitoring of Corrective Actions: Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Infection Preventionist/Nurse Staff Educator/ADON/DNS/Designee. The DNS/Designee will be responsible for completion of this plan of correction. Audits will be completed in regards to Dementia training/Annual Mandatory for certified aides biweekly x 4 then monthly x 3 months. Audits to be completed by Human Resource Director/Nurse Staff Educator/Designee. Audits will be presented at QAPI meetings monthly by the Human Resource Director/DNS to determine continued need. The DNS/Designee will be responsible for completion of this plan of correction. The Administrator has created an audit tool to monitor compliance with CNA annual mandatory education including Dementia education. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA did not receive the required annual in-service training of at least 12 hours. Record review showed the CNA signed for several in-services, including fall prevention, choking prevention, abuse recognition/reporting, oral care, infection precautions, oral hygiene, emergency response procedures, and safe repositioning techniques, but the DSD stated the CNA did not meet the minimum required in-services.
The facility failed to ensure that two of three sampled nurse aides received the required minimum of 12 hours of annual in-service education. Review of policy and personnel files showed the aides did not have documentation of the required training in their records, and HR confirmed the deficiency.
Failure to document required annual nurse aide education. The facility reviewed employee education records and found no evidence that three of five nurse aides completed the required 12 hours of annual training. The facility assessment stated that personnel would receive annual education credits, but the records for the three nurse aides did not show completion of the required training, and the NHA confirmed the missing documentation.
Missing Annual Nurse Aide Training Documentation: Documentation review of 5 of 5 GNA personnel files found no evidence that the required 12-hour annual competency training had been completed within the past 12 months for four GNAs, and one GNA only had proof of training from the prior year with no later record. The HR Mgr stated the facility had no documentation in the files or computer showing when the last training occurred, and the NHA said he could not find the records in the previous DON's office.
The facility failed to ensure that one nurse aide completed the required 12 hours of annual in-service training. Records showed the aide was hired in 2023 and completed only 6 hours and 25 minutes of in-service education during the reviewed annual period, and the NHA confirmed the findings.
The facility failed to ensure that three nurse aides received the required 12 hours of annual in-service education. The NHA stated that no education records could be found for the three nurse aides for the calendar year and confirmed the training requirement was not met.
CNA Did Not Receive Required Annual In-Service Training
Penalty
Summary
The facility failed to ensure that 1 of 5 sampled CNAs, CNA 5, received the required in-service training of no less than 12 hours per year. During review of the facility’s required in-services log book with the DSD on May 21, 2026, CNA 5 was documented as having signed for eight in-services, including fall prevention, choking prevention, abuse recognition/intervention/reporting, oral care, standard/enhanced/droplet/airborne precautions, importance of oral hygiene, emergency response procedures, and safe repositioning techniques. Some entries listed no time, and the DSD stated during interview that CNA 5 did not meet the minimum required in-services.
Failure to Provide Required Annual Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that two of three sampled Nurse Aides received a minimum of 12 hours of yearly in-service education. Review of the facility's Continuing Education policy and Training Requirements-Required In-service Training for Nurse Aides policy showed that compliance with training requirements was a condition of employment and that nurse aide in-service training was to be sufficient to ensure continuing competence and no less than 12 hours per year. Review of the personnel records for NA Employee E2 and NA Employee E3 showed hire dates of 3/12/24 and 4/5/24, respectively, and their files did not contain documentation showing they had received the required minimum 12 hours of in-service training during their respective yearly periods. During an interview, Human Resource Employee E9 confirmed that the facility failed to ensure these two nurse aides received the required yearly in-service education.
Failure to Document Required Annual Nurse Aide Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required annual education for three of five nurse aides reviewed, identified as Nurse Aides 4, 6, and 7. The facility assessment dated January 2026 stated that all personnel, including manager, staff, contract staff, and volunteers, would receive their necessary education credits annually. However, review of the employee education files showed no documented evidence that Nurse Aide 4 completed the required 12 hours of education between 2024 and 2025, no documented evidence that Nurse Aide 6 completed the required 12 hours of education between 2024 and 2025, and no documented evidence that Nurse Aide 7 completed the required 12 hours of education between 2024 and 2025. During an interview, the Nursing Home Administrator confirmed that there was no documented evidence that Nurse Aides 4, 6, and 7 completed the 12 hours of annual training as required.
Missing Annual Nurse Aide Training Documentation
Penalty
Summary
The facility failed to ensure nurse aide competency training occurred no less than 12 hours per year as determined in nurse aides' performance reviews. During a complaint survey, documentation review of 5 of 5 Geriatric Nursing Assistant personnel files showed no evidence that the required annual 12-hour training had been completed within the past 12 months for GNA #25, GNA #26, GNA #27, and GNA #29. GNA #28's file contained documentation that the 12-hour yearly training was completed on 5/20/24, but there was no documentation that the training had been completed again since 2024. During the review on 5/15/26, the Human Resources Manager stated there was no documentation in the personnel files or computer showing when the last 12-hour training occurred and said there could be documentation in the previous DON's office, but was not sure. The Nursing Home Administrator later stated he could not find documentation in the previous DON's office related to any 12-hour training for the GNAs.
Nurse Aide In-Service Training Deficiency
Penalty
Summary
The facility failed to ensure that each nurse aide received 12 hours of annual in-service training for one of three nurse aides reviewed, Employee 1. Review of Employee 1’s personnel record showed that she was hired on April 17, 2023. Review of the training records provided by the facility for Employee 1 for the period from April 2025 to April 2026 showed that she completed only six hours and 25 minutes of in-service education. The Nursing Home Administrator confirmed these findings during interview on May 14, 2026, at 12:04 PM.
Failure to Provide Required Annual Nurse Aide In-Service Education
Penalty
Summary
The facility failed to ensure that all nurse aide staff received a minimum of 12 hours of in-service education training each year for three of three Nurse Aide employees, identified as E13, E14, and E15. During an interview, the Nursing Home Administrator stated that education is tracked by calendar year from January through December and that State Agency requested employee education records for these nurse aides. In a later interview, the NHA stated that the facility was unable to find any education records for E13, E14, and E15 for the year 2025 and confirmed that the facility failed to provide the required 12 hours of annual in-service education for these three nurse aides.
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