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F0944
F

Failure to Provide Required QAPI Training to Staff

East Troy, Wisconsin Survey Completed on 07-24-2025

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 ensure that four randomly selected staff members, including three Certified Nursing Assistants and one Dietary Aide, received the required training on the Quality Assurance and Performance Improvement (QAPI) program. According to the facility's policy, all staff must participate in initial orientation and annual in-service training, which includes QAPI as a required topic. The policy also mandates that training be completed prior to staff providing services to residents, and that documentation of completed training be maintained by the staff development coordinator or designee. During the survey, the surveyor reviewed employee records for the selected staff and found no documentation verifying completion of the required QAPI training. The Nursing Home Administrator confirmed that there was no further documentation available for these staff members and acknowledged ongoing issues with staff education. The lack of required QAPI training had the potential to affect all 39 residents in the facility.

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