Failure to Provide Required Facility-Specific Staff Training
Penalty
Summary
The facility failed to develop and implement all required training programs and did not ensure that both facility and contracted staff received necessary trainings. Record reviews revealed that multiple staff members, including those hired as early as 2019 and as recently as 2025, had not received training specific to the facility's Compliance and Ethics program, Quality Assurance Performance and Improvement (QAPI), and Infection Control and Prevention (ICP). Additionally, contracted staff were missing required communication and behavioral health training, as well as training on facility-specific policies and procedures. The review of employee files showed consistent gaps in documentation of completed trainings for both facility-employed and agency staff. Interviews with the Director of Human Resources confirmed that while an online training program was provided from the corporate office for facility staff, there was no structured orientation or onboarding training for contracted staff, aside from occasional shadowing. The Nursing Home Administrator acknowledged that the QAPI and ICP trainings provided were generic and not tailored to the facility, as required. The lack of facility-specific training and incomplete training records were evident for both permanent and contracted staff, as documented in the reviewed files.