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F0944
E

Failure to Provide QAPI Training to Direct Care Staff

Menomonee Falls, Wisconsin Survey Completed on 11-11-2025

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 direct care staff received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. During a survey, it was found that five randomly selected certified nursing assistants (CNAs) did not have documentation of QAPI training as part of their new hire orientation. The nursing home administrator (NHA) confirmed that the facility uses an online training platform, Relias, for staff education, but transcripts for the selected CNAs did not show completion of QAPI training. The facility's training plan, as outlined in the Facility Assessment, did not include QAPI among the required topics for staff education and competency verification. Further investigation revealed that the process for tracking staff training completion relied on corporate communication, with the NHA depending on emails from a corporate employee to identify outstanding education requirements. When questioned, the corporate employee acknowledged a gap in QAPI training and stated that the module was only assigned to all staff for the fourth quarter of the current year, rather than upon hire. As a result, the five CNAs had not received QAPI training at the time of the survey, potentially affecting all 43 residents in the facility.

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