Failure to Provide and Track Required Annual Nurse Aide Education
Summary
The facility failed to provide and accurately track the required 12 hours of annual education for nurse aides, including essential topics such as dementia care and abuse prevention. Interviews with the ADNS and RN responsible for staff education revealed that the annual mandatory education was delivered primarily through poster boards and post tests in the staff break room, with no formal tracking system for the actual hours completed by each nurse aide. The staff development nurse and the corporate regional educator both acknowledged that they did not monitor the actual time spent on education modules, instead assigning predetermined credit hours regardless of the time staff actually spent on the material. Multiple nurse aides reported that the mandatory education and dementia training took significantly less time than the hours credited, often completing the material in 15 to 60 minutes. The education was self-directed, with answer keys available for copying, and there was no instructor present to answer questions or verify understanding. Some nurse aides did not complete all required modules, and there was no observation or verification of competency for skills, as staff simply signed off on forms themselves. The corporate COO confirmed awareness of issues with the staff education and competency process during the year in question. A review of the facility assessment indicated that the facility's staffing plan required nurse aide competency in areas such as dementia management and abuse prevention, with training to be completed during orientation and annually. However, the facility was unable to provide a policy for mandatory staff education or documentation verifying that nurse aides received the full 12 hours of required education. The lack of a structured, monitored education program and insufficient documentation led to the deficiency.
Penalty
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The facility did not ensure that two nurse aides completed the required 12 hours of annual in‑service education, including dementia management, abuse prevention, and training to address performance weaknesses. One aide had only a brief in‑service on infection control and respirator use, while another had less than four hours of training focused on safe resident handling, mechanical lift use, elopement prevention, and ethics. The DON and the NHA confirmed that the required annual in‑service training had not been completed, resulting in noncompliance with state personnel and staff development regulations.
Surveyors found that multiple NAs did not receive the required minimum of 12 hours of annual in‑service education within 12 months of their hire date anniversary. Facility records showed that each of the reviewed NAs received only 2 to 4 hours of in‑service training during their respective 12‑month periods, despite the facility’s own assessment stating it follows all state and federal guidelines for staff education. No additional training documentation was produced, and the NHA confirmed that the required annual in‑service education had not been provided for these NAs.
The facility did not ensure nurse aides received the required 12 hours of annual in-service training, including dementia care and abuse prevention, for a census of 54 residents and a sample of 14 residents. When surveyors requested documentation of in-service training for the past year, the facility could not locate the binder containing sign-in sheets and training records. Administrative staff reported that staff turnover, including in the position responsible for overseeing nurse aide in-services and documentation, contributed to missing or incomplete records. The written policy on nurse aide qualifications and training did not address the requirement for 12 hours of annual in-service education.
The facility did not ensure that all CNAs received the required minimum of 12 hours of annual in-service training, including topics such as dementia care and abuse prevention. Review of records for several CNAs employed more than one year showed that two CNAs had only seven and eight documented training hours over the prior year. An administrative nurse confirmed the 12-hour annual requirement and the absence of additional training records for these CNAs, and the facility was unable to provide a policy outlining its CNA in-service training program.
The facility did not ensure that all CNAs, including those from a temporary agency who made up about half of the CNA staff, received the required 12 hours of in-service training in areas such as dementia care and abuse prevention. The Administrator acknowledged having no documentation of any trainings completed by agency staff and confirmed that the temporary agency was treated as not responsible for the performance or training of its personnel. Several residents reported that agency staff did not know what was going on, did not seem to care, did not know the residents, and did only the bare minimum, reflecting concerns about the skills and preparedness of these CNAs.
The facility did not provide or document required in-service training and competency evaluations for CNAs, including dementia care and abuse prevention education. Review of multiple CNA files showed no evidence of annual or new hire training or skills competencies. The HR director confirmed that there were no formal competencies or in-services completed and no required online or hands-on training in place. A CNA reported not receiving any formal competency or skills check at this facility, and the DON acknowledged that there had been no established process for annual competencies and that new hire orientation had been limited to verbal information and informal on-the-floor orientation.
Failure to Provide Required Annual In‑Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that two nurse aides received the required 12 hours of annual in‑service training, including dementia management, resident abuse prevention, and training to address identified performance weaknesses. Review of personnel records showed that NA 1 was hired on August 28, 2023, and facility training records for the period April 17, 2025, to April 17, 2026, documented only 31 minutes of in‑service education for NA 1, limited to infection control and respirator use. Review of NA 2’s personnel record showed they were hired on December 19, 2023, and training records for the same period documented only 3 hours and 48 minutes of in‑service education for NA 2, covering safe resident handling, mechanical lift use, elopement prevention, and ethics. In an interview on April 17, 2026, at 12:59 p.m., the DON and the Nursing Home Administrator confirmed that NA 1 and NA 2 had not completed the required annual in‑service training. These findings were cited under 28 Pa. Code 201.19(7) related to personnel policies and procedures and 28 Pa. Code 201.20(a)(6)(d) related to staff development.
Failure to Provide Required Annual In‑Service Training for Nurse Aides
Penalty
Summary
The facility failed to provide the federally required minimum of 12 hours of annual in‑service training for nurse aides within 12 months of their hire date anniversary. Review of the facility’s most recent Facility Assessment, dated 4/15/25, showed that the facility stated it follows all state and federal guidelines for staffing education. However, review of the facility’s "Nursing Assistant In-Service Hours" document showed that five nurse aides did not receive at least 12 hours of in‑service education in their respective 12‑month periods. Specifically, one nurse aide hired on 3/7/86 received 2.00 hours of in‑service education between 3/7/25 and 3/7/26, and another aide hired on 3/6/20 received 2.00 hours between 3/6/25 and 3/6/26. A nurse aide hired on 9/30/91 received 4.00 hours between 9/30/24 and 9/30/25, an aide hired on 12/21/00 received 4.00 hours between 12/21/24 and 12/21/25, and an aide hired on 1/22/24 received 4.00 hours between 1/22/25 and 1/22/26. No additional documentation of in‑service hours was provided to the survey team by the end of the survey. In an interview on 4/10/26, the Nursing Home Administrator confirmed that the facility failed to provide the required 12 hours of annual in‑service education within 12 months of the hire date anniversary for these five nurse aides.
Plan Of Correction
Twelve hours of servicing will be provided for the Nurse Aide who's files were reviewed by the survey team. Beginning next month, the DON or their designee will conduct monthly in-service training for Nurse Aides, totaling 12 required class hours. The HR Director will be educated by the Administrator on the need to provide 12 hours of Inservice education to Nurse Aides yearly. The HR director will audit 10% of nurse aides to ensure they complete the monthly class required to acquire 12 hours of in-servicing. Results of these audits will be presented to the QAPI committee for review and recommendations.
Failure to Ensure Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure nurse aides received the required 12 hours of annual in-service training, including dementia care and abuse prevention, for a census of 54 residents and a sample of 14 residents. During the survey, when records of required nurse aide in-service training for the past year were requested, the facility was unable to locate the binder containing sign-in sheets and documentation of education and training provided to nurse aide staff. Administrative Staff A reported she could not find the in-service binder and noted there had been staff turnover in the past year, including the staff member responsible for ensuring completion of in-services and maintenance of documentation. Administrative Nurse D stated that the director of nurse aides was responsible for ensuring nurse aides completed the required in-services and maintained documentation, but that turnover in this position resulted in some required in-service documentation not being completed or retained. Additionally, the facility’s “Nurse Aide Qualifications and Training Requirements” policy dated 08/10/21 did not include information about the requirement for nurse aides to receive 12 hours of in-service training/education annually. No specific resident medical histories or conditions related to this deficiency were described in the report.
Failure to Ensure Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for CNAs that ensured at least 12 hours of annual education with required topics such as dementia care and abuse prevention. During a survey with a reported census of 40 residents, review of training records for five CNAs employed more than one year showed that two CNAs had less than 12 hours of documented in-service training in the previous 12 months. One CNA, employed since 12/20/23, had eight hours of documented training, and another CNA, employed since 07/22/24, had seven hours of documented training. The Administrative Nurse confirmed that all CNAs were required to have 12 hours of training annually and acknowledged there were no additional training records for these CNAs, and the facility did not provide a policy governing the in-service training program. These findings demonstrate that the facility did not ensure all CNAs received and had documentation of the minimum required annual in-service training hours, nor did it provide evidence of a formal policy to support and maintain the required training program.
Failure to Ensure Required In-Service Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including those provided by a temporary staffing agency, received the required 12 hours of in-service training, including dementia care and abuse prevention. Review of the Client Service Agreement between the facility and the temporary agency showed that the facility acknowledged agency CNAs as independent contractors and agreed that the agency was not their employer and was not responsible for their performance or non-performance. The agreement also documented that the agency had no responsibility for, control over, or involvement in the scope, nature, quality, character, timing, or location of the work performed by these CNAs. During the survey, the Administrator stated she did not have any documentation of trainings completed by the agency staff and confirmed she would not be able to provide any such documentation, noting that approximately 50% of the CNA staff were from the temporary agency. Interviews with residents further described concerns related to the care provided by agency CNAs. One resident stated that agency staff were "horrible" and did not seem to know what was going on. Another resident reported that agency staff did not care and had no idea what they were doing. A third resident stated that agency staff did not know anything about the residents and always did the bare minimum. These resident statements, combined with the lack of training documentation and the facility’s reliance on agency CNAs for about half of its CNA staffing, formed the basis of the deficiency related to failure to ensure required in-service training for all CNAs.
Failure to Provide Required CNA Training and Competency Evaluations
Penalty
Summary
The facility failed to maintain required in-service training and competency evaluations for CNAs, including dementia care and abuse prevention education. Review of five randomly selected CNA employee files (R, S, T, U, and A) showed no documentation of annual or new hire education, training, or competencies. The Human Resources Director stated that any annual competencies or education should be kept in each employee file and confirmed that none of the five CNAs had formal competencies or in-services completed during the new hire process or annually, and that there was no required online or hands-on training in place at the time. A CNA reported she had not received any formal competency evaluation or skills check at this facility, though she had at other facilities. The DON reported that, to her knowledge, there had been no system for annual competencies and that, until approximately two weeks prior, new hire orientation consisted only of verbal information from HR and an informal orientation with staff on the floor. No residents or specific clinical conditions were mentioned in relation to this deficiency.
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