Failure to Complete Mandatory Communication Training
Summary
The facility failed to ensure that mandatory communication training was completed by four out of ten staff members reviewed, including the Director of Nursing (DON), a Registered Nurse (RN-E), and two Nursing Assistants (NA-B and NA-I). This deficiency was identified through a review of personnel records, which showed that these staff members had not completed the required education on effective communication. Interviews with staff revealed that RN-C, responsible for staff training, was aware of the non-compliance, and the DON was only recently informed of the need for such training. The DON had mistakenly believed that providing her continuing education transcripts was sufficient and had not received login information to complete the training until recently. Additionally, the facility's assessment from 2023 highlighted the presence of a Laotian community in the surrounding area and noted that the facility had served Laotian residents over the past five to ten years. While cultural considerations were addressed during admissions and care conferences, the assessment did not specify how staff would effectively communicate with residents who were non-English speakers. This oversight in the facility's assessment process further contributed to the deficiency in staff training on effective communication.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility did not provide required education on effective communication to an RN and four NAs hired over a span of several months. Review of staff training records showed no documentation of effective communication training for these direct care staff, despite regulatory requirements for staff development. The interim administrator confirmed during interview that these employees had not received the mandated communication training.
The facility failed to follow its own staff development policy requiring ongoing education on resident needs and rights. Review of training records showed that multiple nurse aides, LPNs, an RN, and therapy staff did not receive resident rights education at hire or during required annual in-service periods. In total, nine of thirteen reviewed direct care staff members lacked documented training on resident rights, a deficiency confirmed by the Nursing Home Administrator during surveyor interview.
The facility did not ensure that direct care staff received required training on effective communication. Policy required all employees to complete designated trainings within set time frames, and HR reported that education is organized by calendar year. Review of education records showed that two NAs and two RNs lacked any documented communication training for the year reviewed. The NHA confirmed that communication training had not been provided to these direct care staff, resulting in noncompliance with staff development requirements.
A review of personnel files and facility policy revealed that several direct care staff, including an RN, multiple NAs, and an LPN, did not receive required annual training on Effective Communication. The facility's HR confirmed the absence of this training for these staff members, as mandated by regulations.
A review of employee files revealed that several direct care staff, including GNAs and an RN, did not have documentation of required Effective Communication training. The HR Director and Corporate Nurse were unable to produce records confirming the training was completed, citing a lack of systematic record maintenance.
Three direct care staff members, including two nurse aides and an LPN, did not receive required training on effective communication, as confirmed by personnel file reviews and interviews with facility leadership. This failure occurred despite job descriptions and facility policy mandating completion of such training.
Failure to Provide Effective Communication Training to Direct Care Staff
Penalty
Summary
Surveyors determined that the facility failed to provide required training on effective communication for five of five sampled direct care staff members. Review of the facility’s employee listing showed that one RN and four NAs were hired on various dates between 10/30/23 and 12/4/24. Examination of facility-provided education documents and individual training records for these staff members revealed no evidence that they had received education on effective communication as required by facility policy and state regulations. During an interview on 3/14/26 at 1:00 p.m., the Interim Nursing Home Administrator confirmed that the facility had not provided effective communication training to these identified staff members. The deficiency was cited under 28 Pa Code: 201.14(a) Responsibility of licensee, 28 Pa Code: 201.18(b)(1) Management, and 28 Pa Code: 201.20(a)(6)(d) Staff development, based on the lack of documented training and the administrator’s acknowledgment of this omission.
Failure to Provide Required Resident Rights Training to Direct Care Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide required training on resident rights as part of its staff development program. The facility’s policy, last reviewed on 12/5/25, states that there shall be an ongoing, coordinated education program for facility personnel, including training related to the needs and rights of residents. Review of facility documents and in-service training records showed that multiple staff members lacked documented education on the resident rights program, either at the time of hire or during the required annual in-service period. Specifically, a nurse aide hired on 10/24/25 and another nurse aide hired on 11/23/25 did not receive resident rights education upon hire or thereafter. Additional nurse aides, LPNs, an RN, and therapy staff did not have documented resident rights in-service education during the applicable annual periods following their hire dates. In total, nine of thirteen reviewed staff members, including nurse aides, LPNs, an RN, and therapy employees, were found without the required resident rights training. During an interview on 2/13/26, the Nursing Home Administrator confirmed that the facility failed to provide resident rights training for these nine staff members, in violation of 28 Pa Code: 201.14(a), 201.18(b)(1), and 201.20(a)(c).
Failure to Provide Required Communication Training to Direct Care Staff
Penalty
Summary
Surveyors found that the facility failed to provide required training on effective communication to most of the direct care staff reviewed. The facility’s Continuing Education policy dated 9/22/25 stated that all levels of employees are expected to complete required trainings within designated time frames, and the Human Resources Director reported that education is conducted on a calendar-year basis from January through December. However, review of 2025 facility education records showed that a nurse aide (Employee E1), a registered nurse (Employee E3), another nurse aide (Employee E4), and another registered nurse (Employee E6) had no documented training on effective communication. During an interview, the Nursing Home Administrator confirmed that the facility did not provide communication training to these direct care staff members, resulting in noncompliance with staff development and licensee responsibility requirements under 28 Pa. Code 201.14(a) and 201.20(c). No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on the lack of documented communication training for direct care staff within the established education period.
Failure to Provide Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory training on Effective Communication to five out of seven direct care staff members, as required by both federal and state regulations. Review of personnel files for a registered nurse, three nurse aides, and a licensed practical nurse revealed that none had documentation of receiving Effective Communication training within the required annual period following their respective hire dates. The facility's own policy mandates that all staff must complete this training prior to independently providing services to residents, annually, and as necessary based on the facility assessment. During an interview, the Human Resources employee confirmed that the required training had not been provided to these staff members. The deficiency was identified through review of facility policies, training records, and staff interviews, with no evidence found that the affected staff had completed the necessary training within the specified timeframes.
Plan Of Correction
Employee's 3, 5, 6, 8, and 9 will receive the communication training in January 2026. All employees will receive an annual communication training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for communication training. Human Resource Director or designee will audit the training to assure all staff have been educated on the training topic. Audit results will be turned into the Quality Assurance meeting monthly.
Failure to Provide Mandatory Effective Communication Training to Direct Care Staff
Penalty
Summary
Facility staff failed to ensure that all direct care staff received mandatory training on Effective Communication, as evidenced by a review of six employee files. Specifically, the files for three Geriatric Nursing Assistants and one Registered Nurse did not contain documentation showing completion of the required training. During the survey, the Human Resources Director was unable to provide evidence that the training had been completed for these staff members. Additionally, the Corporate Nurse confirmed that education records were not systematically maintained, making it impossible to determine if or when the training was provided.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required training on effective communication to direct care staff members, as evidenced by a review of job descriptions, facility documents, and staff interviews. The Nursing Assistant and Licensed Practical Nurse job descriptions both specify the need to complete all assigned training and education as required by law and regulation. However, personnel file reviews for three staff members—a nurse aide hired in 2014, a nurse aide hired in 2000, and an LPN hired in 2020—showed no record of education or training related to effective communication. Interviews with the Human Resources Director and the Nursing Home Administrator confirmed that these staff members had not completed the necessary education on effective communication, despite the facility's requirement for annual training. This deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(a) Staff Development.
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