Agency RN Abuse Training and QAPI Review Deficiencies
Summary
The facility failed to ensure agency staff were trained on the abuse prevention program and policy as required by the facility’s abuse policy and facility assessment. On 3/23/2026, an agency RN was observed alone trying to untie a resident’s restraints and stated it was the first day working in the facility and that no facility orientation or abuse training had been provided. The resident involved, R6, had diagnoses including nontraumatic intracerebral hemorrhage, morbid obesity, acute respiratory failure, cerebral palsy, dysphagia, stage 3 pressure ulcers, convulsions, tracheostomy/gastrostomy dependence, ventilator dependence, osteoarthritis, depression, and hypertension, and had an active order for mittens related to pulling at the trach. The agency RN stated familiarity with standard abuse policies from prior LTC experience, but the facility’s training documents did not show the nurse had been trained on the facility’s abuse policy or trained in accordance with it. The documents also did not show training on sensitivity to resident rights and resident needs, the prohibition against taking or distributing photographs or recordings of residents or their personal space, or how to assess, prevent, and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects residents and staff. No further evidence was provided that the nurse was educated and competent on the facility’s abuse policy. A second agency RN was later observed alone documenting in a resident’s MAR and also denied receiving any facility orientation or abuse training. That nurse stated uncertainty about what to do if abuse were observed and did not know who the facility’s abuse prevention coordinator was. The facility’s agency training documents again did not show training on the abuse policy, reporting procedures, or definitions of abuse, neglect, exploitation, and misappropriation of resident property. The administrator and DON acknowledged that agency staff should be familiar with the abuse prevention policy, but the facility did not have documentation showing the agency nurses had been trained before working in the facility. Record review also showed the facility did not complete the quarterly review process described in its abuse policy. The QAPI binder lacked documented quarterly review of accident reports, incident reports, and safety committee reports to assess for patterns or trends of suspicious bruising, unexplained accidents, or other unusual occurrences that may constitute abuse, neglect, or mistreatment. The administrator confirmed the review process was not being completed, and the regional operations leader and administrator acknowledged that the required tracking and review documentation was not available.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Abuse Prohibition Training for New Hires: The facility failed to document abuse prohibition training upon hire for an LPN and a nurse aide. Personnel file review showed no evidence that either employee completed new hire orientation or training on the abuse prohibition policy, despite facility policy requiring orientation training that includes abuse prohibition and dementia management/patient abuse prevention. During interview, the NHA, DON, and a regional clinical support nurse confirmed the training should be completed upon hire.
Missing Current Abuse Training Documentation: The facility failed to ensure an RN had documentation of current Dependent Adult Abuse training. HR stated the certificate had just been sent to the staff member and was unsure of the update frequency, while the DON and Administrator confirmed the training should be completed every 3 years. The facility policy addressed abuse, neglect, exploitation, and misappropriation education for new and existing staff.
Missing Abuse Training for Newly Hired Staff: The facility failed to ensure newly hired staff received orientation and training on abuse prohibition upon hire. Personnel files for multiple new hires, including CNAs, a CMA, a housekeeper, and another employee, had no documentation of abuse training. One employee stated they had received no abuse training since hire, and HR, the Administrator, and DON confirmed the records did not show the training had been completed. The facility policy required all new employees to be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation.
The facility failed to ensure annual elder abuse prevention training was completed for an employee who worked as a Speech Therapist Contractor. The personnel record showed prior abuse training, but no documentation of the required annual training for the current year. The Administrator confirmed the training had not been completed, despite the facility policy requiring abuse and neglect prevention training upon hire and annually thereafter.
The facility failed to train agency staff on abuse prohibition, resident abuse prevention, and how to identify and report abuse, neglect, exploitation, and misappropriation of resident property. An LPN working at the medication cart stated the facility had not provided this training, and review of personnel records showed the same gap for another LPN, an RN, and a nurse aide. The NHA confirmed agency staff had not received the required education on the facility’s abuse policies and procedures.
Missing Required Abuse Training for Multiple Staff: The facility failed to ensure required DAA training was completed for 3 of 9 staff reviewed. A CNA hired in the facility had no record of completing DAA training within 6 months of hire, and two other staff members had no documentation of the required 3-year renewal training. The HR Director confirmed the missing training, and the Administrator stated DAA training should be completed within 6 months of hire and renewed every 3 years.
Missing Abuse Prohibition Training for New Hires
Penalty
Summary
The facility failed to ensure abuse training upon hire was completed for two of five employees reviewed, identified as Employee 7, an LPN, and Employee 13, a nurse aide. Facility policy, OPS300 Abuse Prohibition, stated that the Center would implement an abuse prohibition program through employee training for new hires and ongoing training for all employees, including the Abuse Prohibition policy and dementia management and patient abuse prevention. The policy also stated that training and reporting obligations would be provided to all employees through orientation, Code of Conduct training, and at least annually. Review of Employee 7’s personnel file showed a hire date of April 28, 2026, but no documentation that she completed new employee orientation or training on the facility abuse prohibition policy. Review of Employee 13’s personnel file showed a hire date of June 16, 2026, but likewise no documentation that he completed new employee orientation or training on the abuse prohibition policy. During an interview with the NHA, DON, and Employee 1, Employee 1 confirmed that abuse prohibition training should be completed upon hire as part of orientation and had no additional information to provide. The NHA stated the facility had identified issues in its hiring process and had implemented a Performance Improvement Plan.
Missing Current Abuse Training Documentation
Penalty
Summary
The facility failed to ensure 1 of 5 staff members completed the required Dependent Adult Abuse training every 3 years. Review of Staff M’s RN employee file found no documentation of current Dependent Adult Abuse training. During interview, HR stated Staff M did have the training and that a copy of the certificate had just been sent to Staff M, but HR was unsure how often the training needed to be updated and guessed it was annual. The DON later stated the training should be completed every 3 years and that the facility normally tracks when it needs to be updated. The Administrator also confirmed the education should be completed every 3 years. The facility policy titled Abuse, Neglect and Exploitation Policy stated new employees are educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff receive annual education through planned in-services and as needed.
Missing Abuse Training for Newly Hired Staff
Penalty
Summary
The facility failed to ensure newly hired staff received orientation and training on abuse prohibition upon hire. Review of personnel files for CNA #509, CNA #506, CMA #507, Housekeeper #512, and [NAME] #511 showed no evidence of orientation or training on abuse at the time of hire. During interview, [NAME] #511 stated they had received no training on abuse since hire. HR #510 confirmed there was no abuse training documentation in the personnel files and stated the Administrator checked new hires against the abuse registry, with abuse training being done during the yearly in-service. The Administrator, DON, and HR later confirmed the employee files for [NAME] #511, Housekeeper #512, CMA #507, CNA #506, and CNA #509 did not contain abuse training records and they did not know if the training had been completed because there was no record of it. The facility policy titled Abuse, Neglect and Exploitation stated all new employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation.
Missed Annual Elder Abuse Prevention Training for Contractor
Penalty
Summary
The facility failed to ensure elder abuse prevention training was completed timely for 1 of 20 sampled employees, Employee #10, a Speech Therapist Contractor hired on 05/24/2018. The personnel record showed elder abuse training was completed on 01/20/2025, but there was no documentation that annual elder abuse prevention training had been completed in 2026. On 06/11/2026 at 7:52 AM, the Administrator confirmed that Employee #10 had not completed the required annual elder abuse prevention training for 2026, although it should have been completed. The facility policy titled, Abuse/Neglect Prevention and Prohibition Long Term Care, reviewed 05/12/2026, stated employees were to complete abuse and neglect prevention training upon employment and annually thereafter.
Failure to Train Agency Staff on Abuse Prohibition and Reporting Procedures
Penalty
Summary
The facility failed to provide training to agency staff on the facility’s procedures related to abuse, neglect, exploitation, misappropriation of resident property, and resident abuse prevention for four of six employees reviewed. During an observation on the third floor, an LPN employed by a nurse staffing agency was working at the medication cart and stated that the facility had not provided training on the abuse prohibition policy or on how to identify and report abuse, neglect, exploitation, or misappropriation of resident property. There was no documentation that this employee had been trained on the facility’s abuse prohibition policies and procedures during orientation and staff development. Review of three additional nurse staffing agency personnel records showed the same lack of education and training for another LPN, an RN, and a nurse aide. The records did not show that these agency employees received training on the facility’s abuse prohibition policy and procedures, including how to identify and report abuse, neglect, exploitation, or misappropriation of resident property, or on resident abuse prevention. During an interview, the Nursing Home Administrator confirmed that agency staff had not been provided training on the prohibition of all forms of abuse, neglect, and exploitation or on the facility’s specific abuse prohibition policies and procedures.
Missing Required Abuse Training for Multiple Staff
Penalty
Summary
The facility failed to ensure staff completed required Dependent Adult Abuse (DAA) training within 6 months of hire and failed to ensure renewal training was completed within 3 years for 3 of 9 staff reviewed: Staff C, a CNA; Staff D, a CNA; and Staff E, a cook. Staff C’s employee file documented a hire date of 3/27/25, but no DAA certificate showing training completed within 6 months of hire was found. Staff D’s file showed DAA training completed on 5/16/23, but there was no documentation of the required renewal training within 3 years. Staff E’s file showed DAA training completed on 10/22/22, but there was no documentation of the required renewal training within 3 years. During interviews, the HR Director stated Staff C had not completed DAA training, Staff D had not completed the 3-year renewal, and Staff E never completed the correct renewal DAA training. The Administrator stated DAA should be completed within 6 months of hire and renewed every 3 years. Review of the undated Abuse Prevention Program policy showed the facility required abuse prevention, identification, and reporting training for new hires and existing staff as required by CMS.
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