Failure to Maintain Effective Staff Training Program and Ensure Completion of Required Education
Penalty
Summary
Facility staff failed to develop and implement an effective training program for new and existing staff, contracted staff, and volunteers, as required by regulation and based on the facility assessment. Review of the facility’s orientation PowerPoint on 1/22/26 showed that behavioral health topics were not included, despite the requirement that such topics be based on the behavioral health needs identified in the facility assessment for the resident population. Although the list of computer-based training modules included required topics such as effective communication, Resident Rights, Elder Abuse, QAPI, Infection Control, Compliance and Ethics, and Behavioral Health, the infection control module did not include the facility’s own infection prevention and control policies and procedures. During interview, the NHA reported she did not have a copy of the previous NHA’s facility assessment and had not completed a new assessment since returning to the position in 8/2025, resulting in training topics not being aligned with the facility’s assessed needs. Review of individual staff computer-based training transcripts on 1/22/26 showed multiple staff members were not current with required trainings. One GNA had completed only four computerized training modules in 2024, with abuse being the only required topic listed, and had no completed trainings between 2021 and those 2024 modules. An LPN had last completed computerized training modules in 2022, and two other GNAs had not completed computerized training modules since 2024. A laundry aide had not completed Resident Rights training since 2023 and had not completed infection control training that included the facility’s policies and procedures. The Corporate Clinical Resource Nurse, who had served as interim DON and was acting as Nurse Practice Educator, stated that corporate determined and assigned annual computer-based training topics, but the facility had no system to ensure staff actually completed the assigned modules. When these concerns were reviewed with the NHA, she offered no rationale for the deficient practice.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.