Deficiency in Staff Communication Training Compliance
Summary
The facility failed to ensure staff compliance with mandatory communication training, as evidenced by a review of Healthcare Academy reports. In 2024, 73 out of 227 facility staff members did not complete the required communication training. Specifically, 42.6% of Nurse Aides and 34% of Licensed Nurses did not complete the training. The Director of Education Services, responsible for assigning and monitoring course completions, identified staff with incomplete courses and notified department heads. However, the Director of Nursing Services indicated that the goal for annual education was for each staff member to complete 75% of their assigned courses, and acknowledged that some staff members had not completed any courses. The facility's organizational structure showed that the Director of Education Services reported directly to the Administrator and worked autonomously. Despite the policy requiring each staff member to complete mandatory in-services, including effective communication, by the end of the month prior to their annual evaluation, 64 out of 227 facility staff members and 53 out of 119 nursing staff members completed less than 75% of their assigned mandatory courses in 2024. This deficiency highlights a lack of oversight and accountability in ensuring staff compliance with required training, as outlined in the facility's Staff Development Corporate Compliance policy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Ensure Required Effective Communication Training: The facility did not have evidence that a shared employee completed mandatory effective communication training. Personnel and training records showed no completion of the required course, and interviews with HR, CHR, and the Administrator confirmed that annual computerized training was monitored through quarterly assignments and reports, but the employee had not completed the assigned training. The Administrator stated HR and department leadership were new to their roles and the requested annual training policy was not provided.
The facility failed to provide Effective Communication training for one of eight staff members, a nurse aide. Review of the personnel file showed the aide was hired in 2024 and had no documented Effective Communication training during the first year of employment. HR confirmed the training was not provided as required.
The facility failed to ensure required communication training was documented for 8 of 20 sampled employees. A RD, CNAs, an SLP, the IP, an RN, and an LPN lacked evidence of training upon hire, and one RD also lacked annual training documentation. The BOM confirmed the missing records, and the facility policy required communication training during orientation and annually.
The facility failed to provide annual Effective Communication training for two nurse aides. Personnel file review showed the required in-service training was missing for both staff members, and HR confirmed the lapse during interview. Facility policy identified Effective Communication as mandatory training for direct care staff.
The facility failed to ensure effective communications training was completed for an Operations Manager, CNA J, CNA K, and an Activity Director. The Operations Manager had no evidence of completing initial training within the first 21 days of hire, and the other three employees had no evidence of annual training in the prior 12 months. HR and the DON stated staff were expected to complete training within required timeframes, but the requested annual training policy was not provided.
The facility failed to ensure mandatory effective communication training was provided to a sampled RN, LPN, and four CNAs. Training records showed none of the six employees had received this training, and the DON and regional director stated that effective communication was not included in the training program.
Failure to Ensure Required Effective Communication Training
Penalty
Summary
The facility failed to provide required effective communication training for one of 23 sampled staff members, identified in the report as PT F. Personnel records showed PT F had a hire date of 01/31/2025, and the facility’s training log contained no evidence that PT F completed the mandatory effective communication training. Review of the training log for the prior 12 months also showed no evidence of completion of this training 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 view or run reports in the computerized training system. CHR E stated annual training was computer generated quarterly, staff were emailed about required and delinquent courses, and completion was reported to department heads, but also stated both the facility HR and the department head responsible for facility staff were newly employed or recently appointed and were still learning their responsibilities. The Administrator stated HR was responsible for reporting staff completion of annual computerized training, that PT F was a shared employee with another sister facility and had not completed assigned computerized training on effective communication, and that the facility could not provide the required training because the assigned training had not been completed. A policy addressing annual employee training was requested but not provided prior to exit.
Missing Effective Communication Training for Nurse Aide
Penalty
Summary
The facility failed to provide Effective Communication training for one of eight staff members, a nurse aide identified as Employee E27. Review of the employee’s personnel file showed a hire date of 6/1/24 and no Effective Communication training documented 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 the required Effective Communication training for one of eight staff members as required by facility policy and regulation.
Missing Communication Training Documentation for Multiple Employees
Penalty
Summary
The facility failed to ensure initial and annual communication training was completed timely for 8 of 20 sampled employees. Personnel record review showed Employee #4, a Registered Dietician hired on 12/08/2025, had documentation of Communication Training completed on 05/13/2025 but lacked annual training for 2026. Employee #10, a CNA hired on 01/16/2026, Employee #11, a Speech Pathologist hired on 02/03/2026, Employee #12, the Infection Preventionist hired on 03/11/2026, Employee #13, an RN hired on 01/13/2026, 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 lacked documented evidence of Communication 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 the personnel records for Employee #4, #10, #11, #12, #13, #15, #16, and #17 lacked documented evidence of Communication training completed upon hire and annually. The facility policy titled, Nursing Personnel Education and Training, published 11/2016, stated education for new employees and contract staff is provided as part of orientation and scheduled annually, including Communication Training.
Missing Annual Effective Communication Training for Nurse Aides
Penalty
Summary
The facility failed to provide annual training on Effective Communication for two of three nurse aide staff members, Employees E2 and E3. Facility policy stated that compliance with the facility’s standards, policies, procedures, and training program was a condition of employment, and the Training Requirements- Communication Training policy identified effective communication as mandatory training for direct care staff. Review of Employee E2’s personnel record showed a hire date of 3/12/24, but the file did not contain annual in-service training on Effective Communication for the period 3/12/25 through 3/12/26. Review of Employee E3’s personnel record showed a hire date of 4/15/24, but the file did not contain annual in-service training on Effective Communication for the period 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed that the facility failed to provide annual training on Effective Communication for these two staff members.
Missing Effective Communications Training for Multiple Employees
Penalty
Summary
The facility failed to provide mandatory effective communications training for 4 of 28 employees reviewed: an Operations Manager, CNA J, CNA K, and an Activity Director. Record review showed the Operations Manager was hired on 04/24/2026, and the training log provided by human resources showed no evidence that the initial effective communications training was completed within 21 days of hire, as required by the facility's training policy and new hire training acknowledgement. Record review also showed CNA J, hired on 02/21/2024, CNA K, hired on 03/10/2023, and the Activity Director, hired on 11/04/2024, had no evidence in the training logs of completing effective communications training annually during the previous 12 months. During interviews, HR O, HR P, the DON, and the Operations Manager stated that new employees were expected to complete training within 21 days of hire and that supervisors were responsible for ensuring staff completed training within 21 days and annually. A requested policy addressing annual employee training was not provided prior to exit.
Failure to Provide Mandatory Effective Communication Training
Penalty
Summary
The facility failed to ensure that all staff received mandatory training on effective communication for six of six employees reviewed, including one RN, one LPN, and four CNAs. During the extended survey review, the facility administrator was asked to provide training records for the sampled employees, and the records showed that none of the six had received training on effective communication. When the findings were reviewed with the administrator, DON, and regional director of operations, the DON and regional director stated that they identify training needs based on policies and sometimes by talking to people or employees, and that effective communication was not included as a topic in their training program.
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