Deficiency in Staff Training Program
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, affecting 17 employees reviewed for training requirements. The deficiency was identified through interviews and record reviews, revealing that the facility did not provide mandatory annual training on various essential topics such as Communication, Residents Rights, Quality Assurance and Performance Improvement (QAPI), Infection Control, Ethics, Behavioral Health, HIV, Falls, and Restraints. This lack of training was evident across multiple staff roles, including Cooks, Maintenance, Admissions, Certified Nursing Assistants (CNAs), Medication Aides, Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), and administrative staff. Personnel records showed that employees hired as far back as 1996 and as recently as 2023 had not received the required annual training. For instance, a CNA hired in 2010 had no evidence of training in Communication, QAPI, Behavioral Health, HIV, and Restraints. Similarly, a Med Aide hired in 2022 lacked training in Dementia, QAPI, Behavioral Health, and Falls. The HR Manager, responsible for assigning these trainings through an online system, acknowledged the oversight, attributing it to a challenging year. Interviews with the HR Manager and the Administrator highlighted the importance of these trainings in ensuring residents receive proper care and are protected from poor treatment, abuse, and neglect. The facility's policy on in-service training, dated August 2022, outlined the required training topics and emphasized the necessity of completing these trainings before staff provide services to residents and annually thereafter. However, the facility failed to adhere to these policies, as evidenced by the lack of documented training across the reviewed personnel records.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing QAPI Training for an Employee: PT F had no evidence of completed mandatory QAPI training in the facility training log or the prior 12 months of training records. HR stated she was newly appointed and still learning her duties, while CHR E and the Administrator said annual training was computer generated, monitored by HR and department heads, and that PT F had not completed the assigned QAPI course.
The facility failed to provide annual QAPI in-service training for an RN whose personnel file lacked documentation of the required training. The ADON confirmed the missing training during interview, and the record review showed the RN had been hired in 2023 but did not have QAPI training documented for the review period.
Failure to ensure mandatory QAPI training was completed for an employee reviewed for licensure and training requirements. Record review showed no evidence the employee completed QAPI training, and HR stated annual training was assigned quarterly through a computer-generated system with recurring email reminders. HR, the DON, and the Administrator stated HR tracked completion, department heads were responsible for ensuring staff finished assigned training, and there was no policy for required annual QAPI training.
Failure to Provide Required QAPI Training: The facility did not provide required QAPI training for one nurse aide. Review of the employee's file showed a hire date of 6/1/24 and no QAPI training documented during the following year, and HR confirmed the training was not provided as required.
Missing QAPI Training for CNAs: Mandatory yearly QAPI in-service training was not documented for 5 sampled CNAs. The facility assessment listed several yearly staff training topics and competencies, but QAPI was not included in the training plan. The NHA confirmed CNAs are required to complete yearly in-service hours and stated CNA training should include QAPI, though the facility does not provide training directly titled QAPI.
The facility failed to ensure QAPI training was completed and documented timely for 5 of 20 sampled employees. A CNA had no documented annual QAPI training for the current year, and four newly hired employees, including CNAs and an LPN, lacked evidence of QAPI training upon hire. The BOM confirmed the missing documentation, and the facility policy required QAPI education during orientation and annually.
Missing QAPI Training for Staff Member
Penalty
Summary
Mandatory QAPI training was not provided for 1 of 23 sampled staff members, PT F. Record review showed PT F had a hire date of 01/31/2025, but the facility’s training log contained no evidence that PT F completed QAPI training. Review of the training log for the prior 12 months also showed no evidence of QAPI training completion for PT F. During interviews, HR D stated she was newly appointed and was still being trained on her duties, including reviewing and reporting annual training, and did not yet have access to run training completion reports in the computerized system. CHR E stated annual training was computer generated quarterly, staff received emails about required and delinquent courses, and HR and department heads were responsible for monitoring completion and reporting delinquent staff. The Administrator stated HR was responsible for reporting staff training completion, PT F was a shared employee with another sister facility, and PT F had not completed the assigned QAPI training. A policy addressing annual employee training was requested but not provided prior to exit.
Missing QAPI Training for RN Staff Member
Penalty
Summary
The facility failed to provide annual in-service training on Quality Assurance and Performance Improvement (QAPI) for one of five staff members reviewed, RN Employee E22. Review of the RN’s personnel file showed a hire date of 7/1/23, but the file did not include annual QAPI training for the period from 1/1/25 through 12/31/25. During an interview on 8/5/26 at 2:17 p.m., the Assistant Director of Nursing, Employee E10, confirmed that the facility failed to provide QAPI training for this staff member.
Failure to Ensure Mandatory QAPI Training Completion
Penalty
Summary
The facility failed to include mandatory QAPI training as part of its QAPI program for 1 of 23 staff reviewed, MA F. Record review showed MA F had a rehire date of 01/02/2024, and the facility’s training log showed no evidence that MA F completed QAPI training. Review of the training log for the previous 12 months, provided by human resources and the nursing department, also showed no evidence of QAPI training for MA F. During interviews, HR G stated annual required training was computer generated quarterly and staff received recurring emails about required completion and delinquent courses. HR G said completion was reported to department heads during weekday stand-up meetings, but only percentages of completion were reported, not delinquent staff. HR G stated employees were assigned training quarterly and it was the employee’s responsibility to complete training timely, including QAPI in the last quarter of the year. HR G acknowledged she should have monitored employees who were not completing training timely and reported delinquent staff for appropriate disciplinary action. HR H, the DON, and the Administrator stated HR was responsible for reporting staff completion of annual computerized training, and they said there was no policy regarding required annual QAPI training. They also stated staff were assigned computer-generated training quarterly, department heads were responsible for ensuring completion, and delinquent staff should be held accountable, including being removed from the schedule until training was completed.
Failure to Provide Required QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for one of eight staff members, a nurse aide identified as Employee E27. Review of Employee E27's personnel file showed a hire date of 6/1/24 and did not include QAPI program training between 6/1/24 and 6/1/25. During an interview on 7/18/26 at 9:50 a.m., Human Resources Employee E29 confirmed that the facility had failed to provide QAPI program training for one of eight staff members as required.
Missing QAPI Training for CNAs
Penalty
Summary
Mandatory yearly QAPI in-service training was not included for 5 of 5 randomly sampled CNAs: CNA J, CNA K, CNA L, CNA M, and CNA N. The facility assessment, last reviewed 1/2026, stated that staff would receive training and education upon hire, yearly, and as needed, and listed topics such as communication, resident rights, abuse, infection control, and culture change, along with competencies including person-centered care, ADLs, disaster, infection control, and caring for persons with Alzheimer's or another dementia. Surveyor review noted that QAPI training was not included in the facility's training plan. During interview on 7/02/26, the NHA stated that CNAs are required to complete 12 hours of yearly in-service/education and confirmed that CNA yearly training should include QAPI. The NHA also stated the facility does not provide training directly titled QAPI, but instead presents interventions and actions put in place for issues identified. Review of the Nurse Aide In-Service Records for CNA J, CNA K, CNA L, CNA M, and CNA N showed they did not receive documented mandatory yearly QAPI in-service training.
Missing QAPI Training Documentation for Multiple Employees
Penalty
Summary
The facility failed to ensure initial Quality Assurance and Performance Improvement (QAPI) training was completed timely for 5 of 20 sampled employees. Employee #9, a CNA hired on 08/05/2020, had documentation showing QAPI training completed on 09/16/2024, but the personnel record lacked documented evidence of annual QAPI training completed in 2025. Employee #10, a CNA hired on 01/16/2026, Employee #15, an LPN hired on 01/26/2026, Employee #16, a CNA hired on 04/23/2026, and Employee #17, a CNA hired on 11/28/2025, all had personnel records that lacked documented evidence of QAPI training completed upon hire. On 06/29/2026 at 8:43 AM, the Business Office Manager stated there was orientation training upon hire and annual training thereafter, and that agency staff do not go directly through the facility for orientation training. The Business Office Manager confirmed that Employee #9, #10, #15, #16, and #17's personnel records lacked documented evidence of QAPI training completed upon hire and annually. The facility policy titled, Nursing Personnel Education and Training, published 11/2016, stated that education for new employees and contract staff is provided as part of orientation and scheduled annually, including the Quality Assurance Program.
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