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F0943
D

Failure to Provide Timely Elder Abuse Training to Agency CNA Involved in Resident Incident

Gardnerville, Nevada Survey Completed on 05-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an agency contracted Certified Nursing Assistant (CNA), identified as Employee #24, completed initial elder abuse prevention training upon hire. Employee #24 was hired on 11/08/2024 and terminated on 03/05/2025, but their personnel record lacked documented evidence of elder abuse training completion at any point during employment. Facility policy required all staff, including agency staff, to complete abuse training upon hire and annually thereafter. An incident occurred in which Employee #24 was involved with a resident who became verbally agitated and exhibited signs of psychosis during assistance with a brief change. The CNA removed the resident from their room and transferred them to the community dining room while the resident was wearing only a t-shirt and a soiled brief. The resident was left in the dining room with the curtains drawn back, visible to others, while staff observed from outside the room. As a result of this incident, three employees were terminated for policy violations. The lack of required abuse prevention training for Employee #24 was confirmed by both the Director of Nursing and the Administrator.

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