Failure to Educate Staff on Enhanced Barrier Precautions
Summary
The facility failed to ensure that all 160 staff members were educated on Enhanced Barrier Precautions (EBP), which involve the use of gowns and gloves during high-contact resident care activities. This deficiency was identified through observation, interviews, and record review. Specifically, a resident with a gastrostomy tube, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed without any isolation signage or a PPE cart at their room entrance. Interviews with facility staff revealed a lack of awareness and implementation of EBP. A Licensed Vocational Nurse stated he was unaware of EBP and that the facility did not place residents on EBP. The Infection Prevention Nurse confirmed that all staff needed education on EBP, and the Director of Nursing acknowledged the need to follow CDC guidance. Review of the facility's policy indicated that all staff should be trained on EBP, with annual refreshers and ongoing audits, but this had not been carried out.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Required Infection Control Training: The facility failed to provide annual Infection Control in-service training for five staff members, including NAs, an RN, and an LPN. Personnel files did not show credible training for the review period, and the NHA confirmed the missing training during interview. The facility policy required regularly scheduled in-service classes and documentation of attendance.
Missing Infection Control Training for Multiple Staff: The facility failed to provide required infection prevention and control training for 9 of 17 direct care staff reviewed, including CNAs, LVNs, the Dietary Manager, the Activity Director, and the ADON. Record review showed no evidence of initial hire training for several employees and no annual training for one CNA. Interviews with the ADON, HR, Administrator, and DON confirmed the training was not completed as required, despite a facility policy requiring initial orientation and in-service training on infection prevention and control standards, policies, and procedures.
Failure to Provide Required Infection Control Training: The facility did not provide required Infection Control in-service training for an LPN, an RN, and three NAs. The facility’s policy required regular staff education on infection prevention and control, but personnel files showed no annual Infection Control training for the affected staff, and the NHA stated there was no employee education for the prior year.
Missed Infection Control Training for RN. The facility failed to ensure an RN completed mandatory infection control training. Records showed the RN had not completed education including infection control within the last year, and the HRA confirmed the last completion was in 2024. The DON stated staff were expected to complete infection control training twice a year, and the facility assessment called for annual training for clinical staff.
The facility failed to provide infection control training for four of ten staff members, including an RN, an activity employee, and two NAs. Although the inservice education program listed prevention and control of infections/standard precautions as a topic, the training records for these employees did not show infection control training during the applicable annual periods. The NHA confirmed the lapse during interview.
The facility failed to provide evidence of required infection control training for one staff member, a speech and language pathologist, during review of staff records. HR stated that new hires receive required trainings through a third-party provider and that completed trainings are transferred into another software, but she does not personally verify which trainings are required by regulation. Facility documents reviewed included onboarding training for Understanding Bloodborne Pathogens and annual training for Infection Control: Essential Principles.
Failure to Provide Required Infection Control Training
Penalty
Summary
The facility failed to provide Infection Control training for five of five staff members identified in the report: NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8. Review of the facility’s In-Service Training Program policy showed that nurse aide personnel are to participate in regularly scheduled in-service training classes and that attendance is to be recorded on each employee’s Record of In-Service. However, review of the personnel files for each of the five employees did not include credible annual in-service training on Infection Control for the period from 1/1/25 through 12/31/25. The personnel records reviewed showed that NA Employee E4 was hired on 3/20/24, NA Employee E5 on 10/22/19, RN Employee E6 on 5/30/19, LPN Employee E7 on 10/19/15, and NA Employee E8 on 3/9/81. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide Infection Control training for these five staff members. The cited regulations were 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.20(a)(d) Staff development.
Missing Infection Control Training for Multiple Staff
Penalty
Summary
The facility failed to provide mandatory training on the infection prevention and control program standards, policies, and procedures for 9 of 17 direct care staff reviewed. Record review showed no evidence of initial hire infection prevention and control training for CNA K, CNA F, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director, and the ADON, and no evidence of annual infection prevention and control training for CNA E. The personnel files reviewed showed hire dates for each of these employees, but the required infection control training documentation was absent. During interviews, the ADON stated he was not aware the infection control and prevention training had not been completed on his hire date before he started resident care and said staff were assigned training through a computer program. The HR staff member said she was new to the position and was not aware the required infection control training had not been completed for all employees. The Administrator stated staff were initially trained by logging into a website and watching training videos, and acknowledged responsibility for ensuring required orientation and annual training were completed. The DON also stated nursing staff were responsible for receiving infection control training during orientation prior to employment and annually. A facility policy revised 02/2026 required all personnel to participate in initial orientation and regularly scheduled in-service training, including infection prevention and control program standards, policies, and procedures.
Failure to Provide Required Infection Control Training
Penalty
Summary
The facility failed to provide required Infection Control training for five staff members, including one LPN, one RN, and three NAs. Review of the facility’s In-Service Training policy showed that all staff were required to participate in regular in-service education on topics including the infection prevention and control program standards, policies, and procedures, with training to be completed before providing care, annually, and as needed based on the facility assessment. The policy also required documentation of the date and time of training, the topic, a summary of the competency assessment, and the hours completed. During interviews, the NHA stated that the facility had recently made staff complete education and later stated that there was no employee education for 2025 because the previous HR employee did not do the job correctly and the outgoing corporate company was not monitoring the work. Review of the personnel files for LPN Employee E6, RN Employee E7, NA Employee E8, NA Employee E9, and NA Employee E10 showed education test packets dated in March 2026, but no annual in-service training on Infection Control from 1/1/25 through 12/31/25. The NHA confirmed that the facility failed to provide Infection Control training for these five staff members.
Missed Infection Control Training for RN
Penalty
Summary
The facility failed to ensure that mandatory infection control training was completed for 1 of 5 staff members reviewed, RN-B. The facility assessment dated [DATE] indicated that clinical staff were to receive infection control training annually, but review of personnel records showed that RN-B had not completed education including infection control in the last year. During an interview on 4/6/26 at 11:40 a.m., the DON stated she would expect staff to complete abuse training, resident rights training, QAPI training, and infection control training twice a year. During an interview on 4/6/26 at 12:35 p.m., the HRA stated the facility did not usually have staff who remained employed past a year as RN-B had, so RN-B had missed being re-assigned training for resident rights, abuse, and infection control, and confirmed the last time these were completed for RN-B was in 2024. The facility's Sufficient and Competent Nursing Staff policy dated 4/2025 stated that licensed staff would demonstrate the skills and techniques necessary to care for resident needs, including infection control.
Failure to Provide Infection Control Training
Penalty
Summary
The facility failed to provide infection control training for four of ten staff members, including an RN, an activity employee, and two nurse aides. The facility policy for inservice education listed Prevention and Control of Infections / Standard Precautions as a topic, but review of the training records for the identified employees showed no infection control training during the applicable annual training periods. The RN was hired on 2/14/23, the activity employee on 1/6/06, the first nurse aide on 1/9/24, and the second nurse aide on 1/10/23, and their records did not include infection control training. During interview, the Nursing Home Administrator confirmed that the facility failed to provide infection control training for four of ten staff members.
Missing Infection Control Training for Staff Member
Penalty
Summary
The facility failed to provide required infection control training for one of ten staff records reviewed, OSM #3, a speech and language pathologist. On 2/20/26, surveyors requested evidence of infection control training for OSM #3, but a review of records provided by the Director of Human Resources did not show that the training had been completed. During an interview on 2/24/26, the Director of Human Resources stated that new employees receive required trainings through a third-party education provider, that completed trainings are transferred into another third-party software, and that she does not personally verify which trainings are required for each employee or keep up with the specific subject matter trainings required by regulations. Facility documents reviewed included onboarding curriculum listing online required training for Understanding Bloodborne Pathogens and annual training assignments for 2026 listing Infection Control: Essential Principles.
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