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F0944
D

Failure to Complete Mandatory QAPI Training for All Staff

Terrell, Texas 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 ensure that all staff completed mandatory annual training on the Quality Assurance and Performance Improvement (QAPI) program, as required by facility policy. Record review showed that three employees—a registered nurse, a certified nursing assistant, and a licensed vocational nurse—had not received the required annual QAPI training for the period reviewed. The facility's policy, revised in September 2022, mandates that all staff participate in both initial orientation and annual in-service training, including training on the elements and goals of the QAPI program. During an interview, the Administrator confirmed the expectation that all staff complete mandatory annual training to stay updated and refreshed on required topics.

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