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
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The facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to its staff. Review of the annual in-service schedule and staff in-service and computer-based training records over more than a year showed no QAPI-related education. The census documented 87 residents in the facility, and the Administrator in Training confirmed that staff had not received QAPI training, potentially affecting all residents.
The facility did not provide required annual QAPI (Quality Assurance and Performance Improvement) in-service training to its staff. Review of the staff in-service records over more than a year showed no documentation of QAPI training, despite 53 residents residing in the facility during this period. The AIT confirmed that no staff had received the annual QAPI training.
Surveyors found that the facility did not provide required Quality Assurance and Performance Improvement (QAPI) education to most of the sampled staff. Review of the staff development policy showed an expectation for ongoing coordinated education, but records revealed that multiple nurse aides, LPNs, an RN, therapy staff, a dietary worker, and an environmental services worker lacked documented QAPI training either at hire or during required annual in-service periods. The administrator confirmed that eleven of fifteen reviewed employees had not received the mandated QAPI training.
Surveyors found that not all staff had received mandatory QAPI training. During review of five randomly selected employee education files, one staff member hired several months earlier had no documented QAPI training. The Administrator confirmed there was no evidence that this staff member had completed the required QAPI education.
The facility did not provide mandatory Quality Assurance and Performance Improvement (QAPI) training to multiple direct care staff, including NAs, an LPN, and RNs, despite a policy requiring all employees to complete designated education within set time frames. Review of annual education records showed no documented QAPI training for these staff members, and leadership confirmed that QAPI education had not been provided, resulting in noncompliance with state requirements for licensee responsibility and staff development.
Facility staff did not provide required Quality Assurance and Performance Improvement (QAPI) training for a dietary aide, as shown by a lack of credible documentation in the employee's record. The DON confirmed that all staff, including dietary, should receive QAPI and related training, but could not provide evidence that this occurred. No staff training policy was presented when requested.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to all employees as required. Record review showed that the Midnight Census Report dated 3/24/26 documented 87 residents residing in the facility. Review of the facility’s Annual In-Service Schedule revealed that it did not include any in-servicing regarding QAPI. Additionally, review of Staff In-Services and Computer Based Training records dated from 3/1/25 through 3/28/26 showed no evidence that QAPI training had been provided. On 3/28/26 at 9:50 AM, the Administrator in Training confirmed that facility staff had not received QAPI training. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency, only that all 87 residents had the potential to be affected.
Failure to Provide Annual QAPI Training to All Staff
Penalty
Summary
The facility failed to ensure all staff received annual Quality Assurance and Performance Improvement (QAPI) in-service training as required by its QAPI program. A review of the facility’s Daily Census Report dated 1/26/26 showed that 53 residents resided in the facility at that time. Review of the facility’s List of Staff In-services, covering the period from 1/6/25 through 2/3/26, showed no documentation that facility staff received annual QAPI training. In an interview on 2/4/26 at 10:14 AM, the Administrator-in-Training confirmed that no staff had received the annual QAPI training.
Failure to Provide QAPI Training to Majority of Staff
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide required Quality Assurance and Performance Improvement (QAPI) training to the majority of sampled staff. Review of the facility’s Staff Development Program policy, last reviewed on 12/5/25, showed that the facility was to maintain an ongoing, coordinated education program for personnel, including training related to residents’ problems, needs, rights, and technology. However, review of facility documents and personnel in-service training records revealed that eleven of fifteen staff members lacked documented QAPI education as required by this program. The missing QAPI training affected multiple disciplines and hire dates. Several nurse aides (employees E5, E6, and E7) did not receive QAPI education upon hire or within the specified annual in-service periods. Two LPNs (employees E9 and E10) and one RN (employee E11) similarly lacked QAPI in-service education during their respective annual review periods. Therapy staff (employees E12 and E13), a dietary employee (E14), and an environmental services employee (E15) also had no documented QAPI training either upon hire or within the designated annual timeframes. During an interview on 2/13/26, the Nursing Home Administrator confirmed that the facility failed to provide QAPI training for eleven of the fifteen reviewed staff members, in violation of 28 Pa Code sections 201.14(a), 201.18(b)(1), and 201.20(a)(c).
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received mandatory Quality Assurance and Performance Improvement (QAPI) training. During a complaint survey, surveyors reviewed QAPI education records for five randomly selected employees on 2/9/26. One employee, identified as Staff #20, hired on 7/31/24, had no documented completion of QAPI training in their education records. In an interview on 2/9/26 at 2:13 PM, the Administrator confirmed there was no evidence that this staff member had received the required QAPI training.
Failure to Provide Required QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Quality Assurance and Performance Improvement (QAPI) training to direct care staff, as identified through review of policies, education records, and staff interviews. 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 documents showed that a nurse aide (Employee E1), an LPN (Employee E2), an RN (Employee E3), another nurse aide (Employee E4), and another RN (Employee E6) had no documented QAPI training. In a subsequent interview, the Nursing Home Administrator confirmed that the facility did not provide QAPI training to these direct care staff, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.20(c) regarding responsibility of the licensee and staff development. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the lack of required QAPI education for the identified direct care employees.
Failure to Provide Required QAPI Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required Quality Assurance and Performance Improvement (QAPI) training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but there was no credible evidence in the employee's record to show completion of the mandatory QAPI training. The Director of Nursing (DON) acknowledged that her focus was primarily on clinical staff training and that new employees received basic orientation, but could not confirm that QAPI training was included for dietary staff. When asked, the DON agreed that dietary staff should receive training on infection control, abuse, kitchen safety, quality assurance, compliance and ethics, and resident rights before starting their duties. Further review of documentation provided by the DON and Regional Director of Clinical Services revealed a Skills Competency Validation Record for the dietary aide, but it was dated prior to the employee's hire date and was not considered credible evidence of QAPI training. The dietary aide's own training transcript also did not show completion of QAPI training. Additionally, the facility was unable to provide a policy on staff training when requested. No further information or documentation was provided by facility leadership to address the concern.
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