THE PEAKS HEALTH & REHABILITATION

Based on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#4 and #101) included documentation of orientation and in-service education as required by policies and procedure. The deficient practice could result in incompetent care of residents. The facility census was 32 and the sample was 12. Findings include: The personnel file of a certified nurse assistant (CNA/staff # 4) revealed a hire date of August 06,2007. The file revealed no evidence of Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training since April 25, 2021. The personnel file of a certified nurse assistant (CNA/staff # 101) revealed a hire date of May 31,2023. The file revealed no evidence of Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training. An interview was conducted on September 20, 2023 around 3:25 p.m. with the Business Office Manager (staff # 26), he stated that staff # 4's, last in-service training was done on April 25,2021 and staff #101 hasn't completed her new hire orientation in last 3 months. An interview was conducted on September 21, 2023 at 10:15 a.m. with the Director of Nursing (DON/ staff # 51), he stated that new hire staffs are required to complete Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training within 30 days of being hired. He further stated that Inservice training for staff are done annually or as needed. A review of the facility Training Requirements policy revealed that Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment.

§483.95(g) Required in-service training for nurse aides. In-service training must- §483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. §483.95(g)(2) Include dementia management training and resident abuse prevention training. §483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff. §483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

Based on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#4 and #101) included documentation of orientation and in-service education as required by policies and procedure. The deficient practice could result in incompetent care of residents. The facility census was 32 and the sample was 12. Findings include: The personnel file of a certified nurse assistant (CNA/staff # 4) revealed a hire date of August 06,2007. The file revealed no evidence of Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training since April 25, 2021. The personnel file of a certified nurse assistant (CNA/staff # 101) revealed a hire date of May 31,2023. The file revealed no evidence of Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training. An interview was conducted on September 20, 2023 around 3:25 p.m. with the Business Office Manager (staff # 26), he stated that staff # 4's, last in-service training was done on April 25,2021 and staff #101 hasn't completed her new hire orientation in last 3 months. An interview was conducted on September 21, 2023 at 10:15 a.m. with the Director of Nursing (DON/ staff # 51), he stated that new hire staffs are required to complete Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training within 30 days of being hired. He further stated that Inservice training for staff are done annually or as needed. A review of the facility Training Requirements policy revealed that Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment.