Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to ensure all staff received mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program, as evidenced by missing training documentation for two of ten employees reviewed. Employee E8, a housekeeping staff member who began working on 3/26/25, and Employee E7, a dietary staff member who began working on 8/7/25, had no evidence in their records of having completed QAPI training. During record review on 12/11/25 at 1:24 PM, surveyors identified the absence of QAPI training documentation for these two employees, and at the same time, the Scheduling Coordinator (E12) confirmed that there was no evidence that E7 and E8 had completed QAPI training. The finding was later reviewed with the NHA (E1), DON (E2), and ADON (E3) during the exit conference on 12/12/25 at 12:30 PM. No residents were mentioned in the report, and no additional clinical or medical details were provided related to the deficiency.
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