Failure to Complete Required Ethics Training
Summary
The facility failed to ensure ethics training was completed for 19 of 24 employees reviewed for training requirements. Record review showed that the Administrator, DON, Activity Director, multiple LVNs, CNAs, RNs, the ADON, and other staff did not have evidence of annual ethics training in the prior 12 months. In addition, the Dietary Manager, Social Worker, and Restorative Aide did not complete ethics training upon hire. Personnel records and training logs were reviewed for each identified employee. The Administrator had a hire date of 02/08/2021 and no evidence of annual ethics training in the previous 12 months. The DON, hired 11/21/2022, also had no evidence of annual ethics training. The Activity Director, hired 01/05/2021, had no evidence of annual ethics training. The Dietary Manager, Social Worker, and Restorative Aide were hired in 2025 and did not complete ethics training upon hire. Interview with HR, the ADON, the DON, and the Administrator confirmed that HR and the ADON were responsible for ensuring staff completed training upon hire and annually. HR stated the training packet used for new hires did not include ethics training. The ADON stated she was unaware ethics training was not in the packet, and the DON and Administrator stated they were not aware the training packet lacked ethics training. A policy identifying required training topics and frequency was requested from HR and the Administrator but was not provided prior to exit.
Penalty
Resources
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Mandatory QAPI training was not completed for an NA reviewed by surveyors. Personnel record review showed no evidence that the NA had completed QAPI education within the last year, and the DON confirmed the records were not found. The facility policy identified QAPI as a mandatory in-service training class, but did not state how often it must be completed.
Failure to provide required QAPI training for a nurse aide. Facility policy required mandatory QAPI training for staff, but the aide’s personnel file did not show annual in-service training in the required period. HR confirmed the facility did not provide QAPI training for one of three staff members reviewed.
Facility failed to provide required QAPI training for five of five Nurse Aides reviewed. The facility assessment stated all personnel were to receive QAPI education, but the education records for the Nurse Aides showed no documented QAPI training, and the NHA confirmed there was no evidence of annual QAPI education.
The facility failed to provide QAPI training to an LPN, an RN, and four CNAs. Review of training records showed none of the six staff members had received instruction on the facility’s quality assurance program elements and goals, and the DON and regional director confirmed the training program did not include QAPI.
Failure to provide QAPI training to four of five direct care staff was identified. The NHA stated the facility could not locate education records for an LPN, two NAs, and an RN for the year reviewed, and the HR Director confirmed the missing training records.
Failure to Provide Required QAPI Training: The facility failed to provide mandatory QAPI training to staff, with no documented evidence of training in five of 11 personnel files reviewed, including CNAs, an LPN, and the HRD. Interviews confirmed that no QAPI in-services had been provided since the HRD and Administrator began working at the facility, and the facility assessment did not include QAPI education among staff training topics.
Failure to Complete Mandatory QAPI Training
Penalty
Summary
Mandatory QAPI training was not completed for 1 of 10 staff members reviewed, nursing assistant (NA)-J. Review of personnel records showed NA-J had not completed education that included QAPI in the last year. During an interview, the DON was informed that QAPI training records for NA-J were not found in the records provided, and the DON stated that QAPI training was expected to be completed annually. No additional records were received showing that NA-J had completed QAPI training within the last year. The facility's undated Staff Development Program policy stated that all personnel must participate in initial orientation and regularly scheduled in-service training classes, and identified QAPI training as a mandatory in-service training class, but it did not specify how often the training should be completed.
Failure to Provide Required QAPI Training
Penalty
Summary
Conduct mandatory training for all staff on the facility’s Quality Assurance and Performance Improvement (QAPI) Program. Review of facility policy showed that compliance with the facility’s standards, policies, procedures, and training program is a condition of employment, and that the facility will include mandatory training as part of its QAPI program to outline and inform staff of the elements and goals of the QAPI program. Review of the personnel record for Nurse Aide Employee E3 showed a hire date of 4/5/24, and the current file did not contain annual in-service training on QAPI for the period 4/5/25 through 4/5/26. During an interview, Human Resource Employee E9 confirmed that the facility failed to provide QAPI training for one of three staff members, Nurse Aide Employee E3.
Failure to Provide Required QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) Program for five of five Nurse Aides reviewed, identified as Nurse Aides 4, 5, 6, 7, and 8. The facility assessment dated January 2026 stated that all personnel, including managers, staff, and volunteers, were to receive education related to QAPI, but review of each of the five Nurse Aides' 2024-2025 education records showed no documented QAPI training. During an interview on May 18, 2026, at 2:26 p.m., the Nursing Home Administrator confirmed there was no documented evidence that these Nurse Aides received the facility's annual education regarding QAPI.
Lack of Staff Training on QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program included training for staff on the program elements and goals. During review of employee training records for six staff members, including an LPN, an RN, and four CNAs, none had received training on the facility’s quality assurance program elements and goals. During an interview with the DON and regional director, they confirmed that the facility’s training program did not include training on the QAPI program.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
Mandatory QAPI training was not provided to four of five direct care facility staff reviewed, including an LPN, two NAs, and an RN. During interviews, the NHA stated that staff education is tracked by calendar year from January through December and that the State Agency requested employee education records for several staff members. The NHA later stated the facility was unable to find any education records for Employees E11, E13, E14, and E16 for the year 2025. The Human Resources Director confirmed that the facility failed to provide QAPI training to four of five direct care facility staff reviewed.
Failure to Provide Required QAPI Training
Penalty
Summary
The facility failed to conduct mandatory QAPI training for staff, as reflected in the review of personnel files and interviews. Five of 11 personnel files reviewed showed no documented evidence of QAPI training for CNA #464, CNA #465, CNA #466, LPN #338, and HRD #307. The cited employees had hire dates ranging from 04/21/25 through 02/26/26, and the facility census was 151 residents. During interviews, the HRD stated that the facility had not provided any QAPI training or in-services to staff since she began employment in April 2025 and believed the Administrator would handle that area. The Administrator confirmed that QAPI training had not been completed yet since he started employment on 12/08/25. Review of the facility assessment revised 08/01/25 showed staff training topics including communications, residents' rights, abuse, infection control, culture change, identification of changes in condition, and cultural competency, but it did not include education for staff on QAPI as required.
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