Legend Oaks Healthcare And Rehabilitation - New Br
LEGEND OAKS HEALTHCARE AND REHABILITATION - NEW BR in NEW BRAUNFELS, TX — inspection on March 28, 2025.
Found 15 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #85's face sheet, dated 3/27/25, revealed she was admitted to the facility on [DATE], with diagnosis including Chronic Obstructive Pulmonary with acute exacerbation.
potential for actual harm Review of Resident 85's physician orders for March 2025 revealed an order: O2 AT 2-4L/MIN CONTINUOUS PER NC every shift active 1/31/2025 22:00.
Review of Resident 85's annual MDS assessment, dated 2/4/25, revealed there was no indication she was receiving oxygen.
Review of Resident #85's Care Plan, revised on 2/13/25, revealed she was using oxygen related to respiratory illness.
Observation and interview on 03/26/25 at 10:59 AM revealed Resident #85 lying in bed with oxygen infusing via nasal cannula. Resident #85's family member stated he saw staff coming in periodically to check on the concentrator.
Interview on 03/27/25 at 03:56 PM with MDS Coordinator/LVN G revealed Resident #85's annual MDS did not indicate Resident #85 received oxygen.
She stated it was important to accurately reflect Resident #85's status so staff would provide the necessary care and services needed.
Review of a facility policy, Resident Assessment, reviewed on 3/2023, read It is the policy of this facility to ensure that the assessment accurately reflect the resident's status.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
Review of Resident #92's Care Plan, initiated 2/24/25, revealed no indication Resident #92 used side rails for mobility and repositioning.
Observation on 03/25/25 at 11:08 AM Resident #92 lying in bed to the left side with 1/4 side rails up on both sides of the bed.
Observation and interview on 03/25/25 at 12:25 PM revealed Resident #92 sitting in a wheelchair eating his lunch meal. He stated he was doing ok but felt cooped up. He stated life changed since his amputation and reported using the side rails for bed mobility.
Interview on 03/28/25 at 04:45 PM with MDS Coordinator/LVN G revealed the MDS would reflect the use of side rails if they met the criteria of a restraint.
She further stated the use of side rails should be reflected in his Care Plan so staff would be aware that he used them. It would also ensure nursing staff monitored for any risks involved.
She stated Resident #92's Care Plan did not reflect the use of side rails and it could result in staff not monitoring the risks involved and it could further result in an accident or injury.
Review of facility policy, Comprehensive Person-Centered Care Planning, reviewed 2/2025, read It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
F 0692 2.
Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of weight loss/gain,
potential for actual harm party and attending physician will be notified.
technicians and registered dieticians will make recommendations for therapeutic diets.
4.
Care plan will be updated or revised as needed.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
Review of an oxygen manual which Resident #76 and Resident #85 used read in relevant part Caring for your [name] oxygen concentrator.
Filter door with vents.
Inspect the vents periodically and wipe with a dry cloth as needed to remove dust.
Service and maintenance should only be performed by appropriately trained and authorized [name] personnel and/or service centers.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
F 0700 5.
Use of side rails as restraints is prohibited unless necessary to treat a resident's medical symptoms.
potential for actual harm ongoing assessments, and care plans. 7. A device that does not prevent the resident from getting out of bed, or from movement, and or the resident can remove with minimal effort is not considered a restraint.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
F 0755
Review of the facility policy on pharmaceutical services reviewed 12/2024, under policy was It is the policy of this facility to provide pharmaceutical services (including procedures that assure the accurate acquiring,
potential for actual harm under procedures was The pharmacist, in collaboration with the facility and the medical director helps develop and evaluate the implementation of pharmaceutical services procedures that address the needs of
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
Observation of the medication cart on 300 hall on 03/27/2025 at 3:10 PM revealed two small round white pills on the bottom of the top drawer of the medication cart on 300 hall.
The pills were loose and not labeled with no identifying markers to indicate what they were.
Medication cart was locked and secured.
Interview with CMA C on 03/27/2025 at 2:55 PM revealed CMA C could not identify loose pills located in medication carts for the 300 halls and 400 halls. CMA C stated if a loose pill is found in the medication carts staff are to follow the facility policy to dispose of them. CMA C stated loose pills in the medication carts could cause the resident's to go without necessary medications.
Interview with DON on 03/27/2025 at 3:41 PM revealed medications are to be stored in original packaging. DON stated CMAs check the carts daily to ensure they are clean and there are no loose pills. DON stated loose pills in the medication carts would not affect the residents since staff would now dispense loose pills.
Record review facility policy titled [Facility Name] Policy/ Procedure - Nursing Clinical section Care and Treatment subject Medication Access and Storage, E kit access, revised 07/2024, revealed 1.
The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable.
Medications are kept and stored in these containers.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
During an interview on 03/27/2025 at 2:31 p.m. the dietary supervisor stated he did not notice the water in the divided plate when he served the grilled cheese sandwich but stated it could cause cross contamination.
The dietary supervisor further stated the dishes are air dried.
During an interview on 03/28/2025 at 4:59 p.m. the DON stated there was the potential of cross contamination of food by dishes not being dried thoroughly.
The DON further stated it could have the potential for causing infections.
The DON stated she felt it would be multiple people's responsibility to not serve food on improperly dried plates if it was not caught in the kitchen the other staff should catch in passing of trays.
During an interview on 03/28/2025 at 5:11 p.m. the administrator stated residents could get sick if there was cross contamination from not properly handling the dishes.
The administrator further stated the dietary supervisor was responsible to ensure dishes were air dried and even the cook on duty was responsible.
Review of facility's policy Handling Clean Equipment and Utensils, not dated, read Policy: Clean equipment and utensils will be handled properly to prevent contamination.
Procedure: 1.
When handling cleaned and sanitized equipment, staff will avoid touching the parts that will come in contact with the food.
Review of facility's policy Cleaning Dishes/Dish Machine, not dated, read Policy: All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use .Procedures: 9.
Dishes should be air dried on the dish racks .10.
Inspect for cleanliness and dryness and put dishes away if clean.
Review of the Food Code, U.S.
Public Health Service, U.S. FDA, 2022, U.S.
Department of H&HS, revealed, 2-301.14, When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTNESILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
F 0940 O.
Hazard communication (Material Safety Data Sheets, [MSDS])
potential for actual harm Q.
Restraints
R. ADA (American Disabilities Act)
A policy addressing required annual training including QAPI training, ethics training, behavior health training, dementia training, HIV training and fall prevention training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit.
A policy addressing required annual training including QAPI training, ethics training, behavior health training, dementia training, HIV training and fall prevention training was requested from the Administrator on 03/28/2025 at 4:48 PM but was not provided prior to exit.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
F 0941 D.
Fire prevention and safety
potential for actual harm F.
Confidentiality of patient information
G.
Preservation of patient dignity, including provision for privacy
H.
Patient rights and civil rights
I. HIPAA
J.
Signs and symptoms of cardiopulmonary distress
K.
Choking prevention and intervention
L.
Sexual Harassment
M.
Elder Abuse and residents rights
N.
Blood borne pathogens (HIV, Hepatitis B)
O.
Hazard communication (Material Safety Data Sheets, [MSDS])
P.
Resident assessment (MOS, PASARR, PSYCH, Diags.)
Q.
Restraints
R. ADA (American Disabilities Act)
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
The facility failed to ensure Dementia management training was provided to [NAME] D annually.
This failure could place residents at risk of being uninformed due to lack of staff training.
The findings include:
Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023.
Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of dementia training being provided annually prior to March 25, 2025.
The training log for [NAME] D revealed annual dementia trainings was last completed on 01/26/2024.
Interview with the HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days.
The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings.
The HR Manager stated [NAME] D did not show up on any reports of the weekly reports.
The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who were responsible to ensure their staff completed trainings.
The HR Manager stated by not training staff annually it increased the likelihood a staff member could do something wrong and put the residents in harm's way.
Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and Administrator were to ensure staff received their annual trainings.
The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of the department heads to ensure staff completed trainings.
The Administrator stated staff were required to complete trainings to ensure they were up to date on policies and procedures to ensure quality care was being provided.
The Administrator stated if staff were not trained it put residents at risk for receiving poor care.
A policy addressing required annual training including dementia training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit.
A policy addressing required annual training including dementia training was requested from the Administrator on 03/28/2025 at 4:48 PM but was not provided prior to exit.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
The facility failed to ensure required QAPI trainings was provided to [NAME] D annually.
This failure could place residents at risk of being cared for by staff who have been insufficiently trained.
Findings include:
Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023.
Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of QAPI training being provided annually prior to March 25, 2025.
The training log for [NAME] D revealed annual QAPI training was last completed on 01/26/2024.
Interview with the HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days.
The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings.
The HR Manager stated [NAME] D did not show up on any reports of the weekly reports.
The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who are responsible to ensure their staff completed trainings.
The HR Manager stated by not training staff annually it increased the likelihood that a staff member could do something wrong and put the residents in harm's way.
Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and the Administrator were to ensure staff received their annual trainings.
The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of department heads to ensure staff completed trainings.
The Administrator stated staff were required to complete trainings to ensure they were up to date on policies and procedures to ensure quality care was being provided.
The Administrator stated if staff were not trained it put residents at risk for receiving poor care.
A policy addressing required annual training including QAPI training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit.
A policy addressing required annual training including QAPI training was requested from the Administrator on 03/28/2025 at 4:48 PM but was not provided prior to exit.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
The facility failed to ensure standards, policies, and procedures for an infection prevention and control program training was provided [NAME] D annually.
This failure could place residents at risk of being uninformed due to lack of staff training.
The findings include:
Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023.
Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of infection control training being provided annually prior to March 25, 2025.
The training log for [NAME] D revealed annual infection control trainings was last completed on 01/26/2024.
Interview with the HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who have annual trainings due within 30 days.
The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings.
The HR Manager stated [NAME] D did not show up on any reports of the weekly reports.
The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who are responsible to ensure their staff complete trainings.
The HR Manager stated by not training staff annually it increased the likelihood that a staff member could do something wrong and put the residents in harm's way.
Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and the Administrator were to ensure staff received their annual trainings.
The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of the department heads to ensure staff completed trainings.
The Administrator stated staff were required to complete trainings to ensure they were up to date on policies and procedures to ensure quality care was being provided.
The Administrator stated if staff were not trained it put resident at risk for receiving poor care.
Record review of facility policy titled In Service Training Program, dated April 2004, revealed 8.
The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics):
A.
Problems and needs of the aged chronically ill, acutely ill, and disabled patients
B.
Prevention and control of infections
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
F 0946 Provide training in compliance and ethics.
potential for actual harm Based on interview and record review, the facility failed to provide mandatory ethics training for 1 (Cook D) of
The facility failed to ensure ethics training was provided to [NAME] D annually.
This failure could place residents at risk of being uninformed due to lack of staff training.
The findings include:
Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023.
Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of ethics training being provided annually prior to March 25, 2025.
The training log for [NAME] D revealed annual ethics trainings was last completed on 01/25/2024.
Interview with the HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days.
The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings.
The HR Manager stated [NAME] D did not show up on any reports of the weekly reports.
The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who were responsible to ensure their staff completed trainings.
The HR Manager stated by not training staff annually it increased the likelihood that a staff member could do something wrong and put the residents in harm's way.
Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and the Administrator were to ensure staff received their annual trainings.
The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of department heads to ensure staff completed trainings.
The Administrator stated staff were required to complete trainings to ensure they were up to date on policies and procedures to ensure quality care was being provided.
The Administrator stated if staff were not trained it put resident at risk for receiving poor care.
A policy addressing required annual training including ethics training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit.
A policy addressing required annual training including ethics training was requested from the Administrator on 03/28/2025 at 4:48 PM but was not provided prior to exit.
676392
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676392 B.
Wing 03/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130
The facility failed to ensure behavioral health training was provided to [NAME] D annually.
This failure could place residents at risk of being uninformed due to lack of staff training.
The findings include:
Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023.
Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of behavior health training being provided annually prior to March 25, 2025.
The training log for [NAME] D revealed annual behavior health training was last completed 01/26/2024.
Interview with the HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days.
The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings.
The HR Manager stated [NAME] D did not show up on any reports of the weekly reports.
The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who were responsible to ensure their staff completed trainings.
The HR Manager stated by not training staff annually it increased the likelihood a staff member could do something wrong and put the residents in harm's way.
Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and the Administrator were to ensure staff received their annual trainings.
The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of the department heads to ensure staff completed trainings.
The Administrator stated staff were required to complete trainings to ensure they were up to date on policies and procedures to ensure quality care was being provided.
The Administrator stated if staff were not trained it put resident at risk for receiving poor care.
A policy addressing required annual training including behavior health training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit.
A policy addressing required annual training including behavior health training was requested from the Administrator on 03/28/2025 at 4:48 PM but was not provided prior to exit.
676392