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F0943
E

Failure to Provide Required Staff Training on Abuse, Neglect, and Reporting Procedures

Pleasant Grove, Utah Survey Completed on 08-20-2025

Penalty

Fine: $72,510
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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 provide staff training that met minimum requirements for educating staff on abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting such incidents and preventing abuse and neglect. Interviews with staff, including a nursing assistant and a registered nurse, revealed that while some education was provided, it was generally limited to addressing issues that needed correction and did not consistently cover the required topics. Staff were unclear about the content and purpose of Quality Assurance and Performance Improvement (QAPI) meetings, and there was no evidence that education on consent or comprehensive abuse prevention was included in the training. Review of in-service training records from January through July showed that none of the agendas included specific abuse training. While there were trainings on dementia, assault, de-escalation, and communication, these did not define abuse, explain its types, outline reporting procedures, or clarify who could give consent. The administrator acknowledged that the abuse training needed updating and that current education did not ensure staff understanding or practice of the required concepts.

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