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F0940
F

Failure to Maintain Effective Staff Training Program

Three Rivers, Michigan Survey Completed on 10-30-2025

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 maintain an effective training program for all new and existing staff members, as evidenced by interviews and record reviews. The Director of Nursing (DON) reported that the facility previously used a computer-based training platform, but after discontinuing the service, they lost access to records of completed staff training. There was no current staff training program in place, and any training that was completed was supposed to be recorded in employee files. However, a review of employee files for several CNAs revealed no documentation of training related to Quality Assurance and Performance Improvement (QAPI), Infection Control, Compliance and Ethics, Communication, or Resident Rights within the past 12 months. Further interviews with the Nursing Home Administrator (NHA) confirmed that the facility had not been tracking staff training and was aware that some training requirements had not been met. The NHA also stated that there was no Performance Improvement Plan in place to address the lack of annual staff training. A review of the facility's assessment indicated that the training program was supposed to include ongoing training for existing staff, covering topics such as effective communication, resident rights, infection control, QAPI, and compliance and ethics, but this was not being implemented as described.

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