Failure to Maintain Effective Staff Training on Resident Safety and Medication Management
Summary
The facility failed to maintain an effective training program for both facility and agency staff, resulting in multiple deficiencies related to resident safety and medication management. In one incident, a resident with severe cognitive impairment and a history of elopement risk was able to exit the facility unsupervised. Staff did not respond to door and Wanderguard alarms in a timely manner, and agency staff were unfamiliar with the alarm systems and elopement protocols. Interviews revealed that staff were unsure of procedures during the incident, and agency nurses had not received adequate orientation or training on facility-specific safety protocols, including the use of alarms and elopement response. In separate incidents involving the administration of controlled substances, discrepancies were found in the documentation and handling of narcotic medications for two residents. There were inconsistencies between the medication administration records (MAR) and proof of use sheets, with doses recorded on one document but not the other. Agency nurses were not properly educated on the facility's narcotic handling procedures, and shift-to-shift narcotic counts were not always completed or documented correctly. Some agency staff signed narcotic count sheets with only the word "agency" instead of their names, and there were missing counts on certain days. Interviews with staff and review of orientation materials revealed that agency nurses did not consistently receive or complete required training on critical facility policies, including those related to elopement and controlled substances. The orientation checklist for agency personnel did not include post-tests or detailed information on door alarms, Wanderguard systems, door codes, or controlled substance administration. As a result, both new and existing staff, including agency personnel, were inadequately prepared to ensure resident safety and proper medication management.
Penalty
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The facility failed to maintain an effective staff training program based on its facility assessment to ensure LPNs had documented competency for PICC line care and IV medication administration. A resident with osteomyelitis had a PICC line ordered for maintenance and received IV Vancomycin through the line, but employee records contained no competency validation for the LPNs who administered the medication, and the NHA and DON could not provide proof of completed PICC-related competency before care was given.
The facility failed to provide annual emergency preparedness training to all staff members. Review of personnel in-service records and staff interviews showed that training was only given during new-employee orientation and was not completed each year. The D of Maintenance and the NHA both confirmed the lapse in required staff training.
The facility failed to maintain a competency-based nursing orientation process and lacked required competency records for newly hired RNs and LPNs. Staff reported that orientation had been shortened from eight days to three or four days, nursing leadership was excluded from final competency review, and completed checklists were sent to HR instead of the DON. The DON confirmed an RN was placed on the floor independently without verified competencies and that this occurred during the RN’s first solo shift on the 28-resident front medication cart, resulting in a widespread medication error incident.
A facility failed to maintain an effective training program for nephrostomy tube care and flushing. Staff gave conflicting descriptions of the procedure, with one RN describing standard precautions and regular gloves while an LPN described a sterile procedure requiring sterile gloves and a sterile syringe. A resident with a nephrostomy tube was later hospitalized with fever, vomiting, and acute pyelonephritis related to the tube, and the DON and NHA confirmed there were no nephrostomy flushing competency checkoffs for nursing staff.
Missing Required Staff Training: Surveyors found that required annual training was not completed for a CNA and multiple LPNs. Missing topics included effective communication, resident rights and responsibilities, QAPI, infection control, compliance and ethics, behavioral health, and the annual in-service training for nurse aides. The facility stated it did not have a policy related to staff training requirements, and records reviewed were the only training documents provided.
Inadequate van transport safety training led to residents being improperly secured during outings. Staff who drove or assisted with van transport reported little or no training on lap belts, shoulder harnesses, or wheelchair tether straps, and one resident fell from her wheelchair when not properly restrained. Another resident reported the van was driven too fast and caused bruising while she was riding in her wheelchair.
Missing competency validation for PICC line care and IV medication administration
Penalty
Summary
The facility failed to develop, implement, and maintain an effective staff training program based on its facility assessment to ensure licensed nursing staff had the knowledge, skills, and documented competencies needed to provide care for a resident with a PICC line. The facility assessment identified that the facility routinely cared for an average of three residents receiving high-risk intravenous or intramuscular medications or infusions and stated that staff would receive education consistent with their assigned responsibilities, with competencies and skill sets identified to meet resident needs. Pennsylvania nursing regulations cited in the report required RNs and LPNs performing intravenous therapy, including central venous catheter care, to complete approved education, supervised clinical instruction, and competency demonstration. Resident 6 was admitted with osteomyelitis and had a physician order to maintain a PICC line and monitor the insertion site each shift for signs of infection or infiltration. A later physician order directed Vancomycin 1,000 mg IV daily for treatment of osteomyelitis. The July 2026 MAR showed an LPN documented administering Vancomycin through the PICC line on multiple occasions. Employee records showed the two LPNs involved were hired in February 2026 and June 2026, but their files contained no documented competency assessment or validation for PICC line management, central venous catheter patency, or administration of medications through a central venous catheter. The competency documentation section also had no completion dates entered for either employee, and during interview the NHA and DON were unable to provide documentation showing either LPN had completed competency validation before providing care to Resident 6.
Failure to Provide Annual Emergency Preparedness Training
Penalty
Summary
The facility failed to provide annual emergency preparedness training to all staff members. Review of the facility personnel in-service training records and staff interview showed that emergency preparedness training was only provided during new-employee orientation and was not completed annually for each staff member. Federal regulations cited in the report require LTC facilities to provide emergency preparedness training at least annually and maintain documentation of the training. During interviews, the Director of Maintenance confirmed that annual emergency preparedness training was not being provided, and the Nursing Home Administrator also confirmed that the facility failed to provide this training to all staff members.
Incomplete Nursing Orientation and Competency Verification
Penalty
Summary
The facility failed to develop and implement a comprehensive, competency-based nursing orientation program and failed to maintain required competency records in the personnel files of newly hired nurses. Review of the files for four nurses hired within the last seven months showed no orientation documents or completed competency evaluations specific to the LPN or RN roles. The facility’s Facility Assessment dated 10/23/25 required nursing staff competencies at hire and annually, including lifts, isolation, PPE donning and doffing, hand hygiene, wound and skin assessment, safe drug administration, medication pass, wound care, blood glucose monitoring, and medication errors. During interviews, staff described a shortened orientation process and a lack of nursing department oversight. An RN in orientation stated floor nurses signed off on checklists but questioned whether the compressed training timeframe was sufficient. An LPN who was precepting the RN stated orientation had recently been reduced from eight days to three days and was insufficient for learning the unit and medication pass responsibilities. The DON confirmed RN-A had been placed on the floor independently without proper competency evaluations and that this occurred during RN-A’s first solo shift on the 28-resident front medication cart, resulting in a widespread medication error incident. The DON, scheduler, and administrator also confirmed that completed competency forms were routed to HR rather than nursing leadership, and that the facility lacked a valid process to verify nurse competency before assigning independent floor shifts.
Inconsistent Nephrostomy Tube Training and Missing Competency Checkoffs
Penalty
Summary
The facility failed to implement and maintain an effective training program regarding nephrostomy tube care and flushing procedures. During review of complaint #3067494, surveyors found that Resident #4 had a nephrostomy tube and had been hospitalized from [DATE] to 6/17/26 with fever and vomiting and acute pyelonephritis. The hospital infectious disease consultant documented acute pyelonephritis related to the nephrostomy tube, with no other symptoms suggesting an alternative cause. Staff interviews showed inconsistent understanding of the nephrostomy flushing procedure. One RN stated the tube was unscrewed, cleaned with alcohol, and flushed with 10 mls of NSS using standard precautions and regular gloves. In contrast, an LPN stated the procedure was sterile, requiring sterile gloves, alcohol cleansing, and a sterile syringe with 10 ml of NSS, and said she had been trained by the staff development nurse years earlier but was not sure whether a competency checkoff had been completed. The DON stated the staff development nurse no longer worked at the facility and that she was covering that role, and the NHA confirmed the facility did not have nephrostomy flushing competency checkoffs for nursing staff and that the staff development role was vacant.
Missing Required Staff Training
Penalty
Summary
The facility failed to ensure staff were trained on required annual trainings. During review of training records for a CNA and multiple LPNs, surveyors found missing training subjects including effective communication, resident rights and responsibilities, QAPI, infection control, compliance and ethics, behavioral health, and the required annual in-service training for nurse aides. Specifically, training records reviewed for V6, V40, V47, V12, V23, and V5 showed various required topics were not completed. On 7/1/26, V18 stated the facility did not have a policy related to staff training requirements and that all training documents available for those staff had been provided. A resident matrix dated 6/4/26 documented 64 residents living in the facility.
Inadequate Van Transport Safety Training
Penalty
Summary
The facility failed to develop and implement an effective training program for staff who transported residents in facility vans and secured residents during transport. Staff interviews showed that multiple employees who drove the vans or assisted with transport had not received training on van-specific safety procedures, including proper use of lap belts, shoulder harnesses, and wheelchair tether straps. Several staff members stated they were unaware of the lap belts or had only received limited instruction on lowering and raising the lift gate or ramp, and one staff member said the training video was not van-specific and did not include seat belt and harness application. Review of the transportation log showed 13 different staff initials for van driving during the reviewed period, and no education could be found for van safety, restraint use, or seat belt education for those staff. Resident #1 was involved in a van incident in which she fell out of her wheelchair because she was not properly secured with a lap belt, and staff reported that the wheelchair had been tethered to the van without the required waist/lap belt. Resident #1 showed a healed abrasion scar on her right knee from the fall and stated she was not secured tightly enough and slid out of her chair under the seatbelt. Resident #4 also reported being upset by the van driver’s speed and said the van was traveling fast enough to cause her to bounce in her wheelchair and sustain bruises. Staff interviews further indicated that the designated van driver and other staff did not consistently know how to apply the required restraints, and one staff member described observing prior practice in which the wheelchair was not secured with the full set of tether straps and no seatbelt was placed on the resident.
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