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F0940
D

Failure to Maintain Effective Staff Training Program

Susanville, California Survey Completed on 07-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective training program for its staff as required by its own policies and procedures. According to the facility's policy, all personnel are required to attend scheduled training classes, and make-up classes should be provided for any missed sessions. However, record review and interviews with the Director of Staff Development (DSD) revealed that attendance at several mandatory in-services was extremely low, with only two or three staff members attending each session. Specific in-services with poor attendance included topics such as Theft and Loss-Residents Personal Property, Dementia Module #2, Abuse and Neglect, and Advanced Directives and POLST. Some required in-services were not conducted at all during the year, and others were not rescheduled after being missed. The DSD confirmed that, although in-services were scheduled twice a week to allow staff a second opportunity to attend, there were no formal attempts to provide make-up classes for those who missed both sessions. Instead, missed content was sometimes addressed through one-on-one education or during team huddles, but there was no documentation or structured process for these alternatives. This lack of adherence to the facility's own training attendance policy had the potential to impact residents' ability to attain or maintain their physical, mental, and psychosocial well-being.

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