Cook D, hired in December 2023, last completed behavioral health training on January 26, 2024. Federal inspectors found no evidence the employee received the required annual training until March 25, 2025 — over 14 months later.
The gap persisted despite the facility's reliance on a training program called Relias that was supposed to identify staff needing annual training within 30 days of their due date.
"By not training staff annually it increased the likelihood a staff member could do something wrong and put the residents in harm's way," the HR Manager told inspectors on March 28.
The HR Manager said he ran weekly reports from Relias to identify employees who needed to complete annual training. Those reports went to department heads, who were responsible for ensuring their staff completed the required courses.
But Cook D never appeared on any of the weekly reports, according to the HR Manager. He couldn't explain why the system failed to flag the overdue training.
The Administrator echoed the concern about untrained staff during a separate interview the same day. "If staff were not trained it put resident at risk for receiving poor care," the Administrator said.
Both the HR Manager and Administrator described a clear chain of responsibility: HR runs the reports, department heads ensure compliance, and everyone works together to keep training current. The system exists, they said, to ensure staff stay "up to date on policies and procedures to ensure quality care was being provided."
Yet the system failed for over a year with Cook D.
When inspectors asked for the facility's policy on required annual training, including behavioral health training, neither the HR Manager nor the Administrator could provide it. The requests were made during their respective interviews on March 28, but no policy was produced before inspectors completed their review.
The training requirement isn't arbitrary bureaucracy. Behavioral health training helps staff recognize and respond appropriately to residents experiencing mental health crises, dementia-related behaviors, or other psychological distress. In a nursing home setting, untrained staff might misinterpret a resident's behavior or respond in ways that escalate rather than defuse difficult situations.
Federal regulations require facilities to provide this training annually to ensure staff maintain current knowledge and skills. The requirement applies to all staff who might interact with residents, including dietary workers like Cook D.
The failure at Legend Oaks reveals a troubling gap between policy and practice. The facility had the technology — Relias generates automated reports. They had assigned responsibilities — HR runs reports, department heads follow up. They even had administrator oversight — both the HR Manager and Administrator understood their roles in the process.
But none of that mattered when the system simply didn't work.
The Administrator and HR Manager both acknowledged the stakes. Untrained staff put residents at risk. Poor care becomes more likely when employees don't receive required education. The facility's own leadership understood these consequences.
Cook D finally received the overdue behavioral health training on March 25, 2025 — three days before inspectors arrived. The timing suggests the facility discovered the gap during preparation for the federal inspection, not through their regular monitoring process.
For 14 months, Cook D worked in the facility without current behavioral health training. During that time, the weekly reports that were supposed to catch such oversights ran as scheduled. Department heads received their assignments to ensure compliance. Administrators oversaw the process they described to inspectors.
The system worked for 27 other employees whose training records inspectors reviewed. It failed for one.
That failure, the facility's own managers said, put residents at risk of receiving poor care from staff who might do something wrong because they lacked proper training.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legend Oaks Healthcare and Rehabilitation - New Br from 2025-03-28 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Legend Oaks Healthcare and Rehabilitation - New Br
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