This citation pertains to intake # MI00138591 Based on observations, interview, and record review the facility failed to provide in depth Dementia Care training to all current, newly hired and agency employed staff resulting in an incident of staff to resident abuse for Resident #21, with a potential for a decline in physical, mental, and psychosocial well- being and unmet care needs for all residents with dementia. Findings include: Review of Preventing The Abuse of Residents with Dementia or Alzheimer's Disease In The Long-Term Care Setting: A Systematic Review, Published by The National library of Medicine, 2019, revealed . there is an increasing rate of abuse in the long-term care setting, specifically for those individuals with either dementia or Alzheimer's. …
F949
Administration Deficiencies
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F949 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F949 finding.
The harm level
How severely F949 is cited
0.4% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G10.4% | H— | I— |
| No harm, potential for more than minimal | D7728.6% | E11241.6% | F5921.9% |
| No harm, potential for minimal | A— | B155.6% | C51.9% |
In the surveyor’s words
What an F949 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and document review, the facility failed to ensure 8 of 8 staff (registered nurse (RN)-D, RN-E, nursing assistant (NA)-A, NA-B, and NA-C, NA-D, NA-E, and the social services coordinator (SSC) had received initial and/or annual training on Alzheimer's disease or related disorders, assistance with Activities of Daily Living (ADL), problem solving with challenging behaviors, and communication skills.Findings include: Review of the facilities current Course Report identified they had 3 mandatory courses available for training: Comprehensive View of DementiaChallenging Behaviors: Care and Interventions for Individuals Experiencing Dementia. Alzheimer's Disease: The Facts Review of the social service coordinator's (SSC) employee file identified they had a hire date of 2/21/26. …
Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for one of five employees (Employee E12). Findings include: Review of facility policy Facility Assessment last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included Dementia and Psychosocial Needs.Review of PT Employee E12's personnel record indicated a hire date of 4/23/18. …
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