Facility Assessment Lacked Required Training Frequency Documentation
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately documented the training requirements for all direct care staff. Specifically, the Facility Assessment completed on 05/30/2025 listed required training topics and the staff groups to be trained but did not include documentation of the frequency for these trainings. During interviews, the Administrator confirmed that the Facility Assessment was current and acknowledged that it did not specify how often staff needed to be trained, despite this being a requirement. Additionally, the Administrator stated that only Facility Leadership was required to complete QAPI training, not all staff, and was unaware of the requirement for broader staff participation in this training. The facility's policy, reviewed on 05/06/2025, requires the Facility Assessment to be updated with training requirements to meet resident needs and regulatory standards. However, the lack of documentation regarding training frequency and incomplete identification of required staff for certain trainings resulted in a deficiency. There is no mention of specific residents or their conditions in relation to this deficiency.