Failure to Train Staff on Communication Boards and Interpreter Services
Summary
The facility failed to ensure staff were aware of and trained on the location and use of the communication board and language translation line for residents with language barriers. During interviews, CNA 1, CNA 3, LVN 1, CNA 14, LVN 4, and RN 4 stated they were not aware of translator services or the language translation line, and several staff stated they had not been trained to use translator services. The Director of Staff Development stated staff received communication training and that communication methods were to be resident-centered, but also stated she was not aware of translator services in the facility at first and later stated translator services were available but were not included in staff in-services or training. Review of the facility’s 2022 Communicating Effectively training and the 7/2025 Resident Rights/Communication in-service showed that availability of and use of translator services were not taught to staff. Resident 32 was admitted on 08/21/2013 and re-admitted on 09/26/2018 with diagnoses including hypertension, dorsalgia, presbyopia, fracture of the nasal bones, and dysphagia oropharyngeal phase. The resident’s MDS dated 10/10/2025 indicated severely impaired cognition and a need for supervision or touching assistance. During observation, Resident 32 was speaking Farsi and was not able to understand questions asked in English, responding only with “Farsi. Farsi.” No communication board was observed in the resident’s room. During interviews in the resident’s room, CNA 14 stated the resident could vocalize basic needs and use basic hand gestures but could not ask or answer more in-depth questions because of the language barrier, and CNA 14 was not aware of a communication board location or the existence of a language translation line. LVN 4 stated the resident was understood through body language but was unaware of whether a communication board was in the room, at the nursing station, or elsewhere in the facility, and was also not aware of a language translation line. RN 4 stated a communication board should be available at every nurse’s station and that all staff should be trained on the location and use of communication boards and translation lines. The facility policy titled Accommodation of Residents’ Communication Needs stated staff would provide adaptive devices as needed, including communication boards/charts and interpreter services for foreign languages and sign language.
Penalty
Resources
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The facility failed to provide annual Effective Communication training for two nurse aides. Personnel file review showed the required in-service training was missing for both staff members, and HR confirmed the lapse during interview. Facility policy identified Effective Communication as mandatory training for direct care staff.
The facility failed to ensure mandatory effective communication training was provided to a sampled RN, LPN, and four CNAs. Training records showed none of the six employees had received this training, and the DON and regional director stated that effective communication was not included in the training program.
The facility failed to ensure agency staff completed required communication training. Record review showed no documentation that agency CNA P, CNA Q, and an LN had completed the training, and Administrative Staff B stated the facility expected the agency to have already provided the required in-services before scheduling staff. The facility also could not provide a policy on required staff in-services.
The facility failed to provide Communication training to five of five direct care staff members reviewed, including an LPN, three NAs, and an RN. The NHA stated that education is tracked by calendar year and that no education records could be found for the identified staff for the prior year. The HR Director confirmed the lack of Communication training records for these staff members.
The facility did not ensure that 5 of 5 CNAs reviewed received required communication training. The CNAs had all worked at the facility for more than 1 year, but the facility could not provide evidence of the training. The HR Director said HR handled onboarding only and did not track annual training, while the NHA and DOO confirmed there was no evidence of the training and no organized system for employee training records.
Incomplete Staff Training Documentation: The facility failed to ensure all staff received mandatory education related to effective communication. The in-service tracking sheets listed topics and attendance, but there was no documentation of the subject matter covered, no agenda used for monthly in-services, and no record of what educational material was presented. The Administrator stated the training was provided from memory and the facility could not ensure each staff member received it.
Missing Annual Effective Communication Training for Nurse Aides
Penalty
Summary
The facility failed to provide annual training on Effective Communication for two of three nurse aide staff members, Employees E2 and E3. Facility policy stated that compliance with the facility’s standards, policies, procedures, and training program was a condition of employment, and the Training Requirements- Communication Training policy identified effective communication as mandatory training for direct care staff. Review of Employee E2’s personnel record showed a hire date of 3/12/24, but the file did not contain annual in-service training on Effective Communication for the period 3/12/25 through 3/12/26. Review of Employee E3’s personnel record showed a hire date of 4/15/24, but the file did not contain annual in-service training on Effective Communication for the period 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed that the facility failed to provide annual training on Effective Communication for these two staff members.
Failure to Provide Mandatory Effective Communication Training
Penalty
Summary
The facility failed to ensure that all staff received mandatory training on effective communication for six of six employees reviewed, including one RN, one LPN, and four CNAs. During the extended survey review, the facility administrator was asked to provide training records for the sampled employees, and the records showed that none of the six had received training on effective communication. When the findings were reviewed with the administrator, DON, and regional director of operations, the DON and regional director stated that they identify training needs based on policies and sometimes by talking to people or employees, and that effective communication was not included as a topic in their training program.
Failure to Verify Required Communication Training for Agency Staff
Penalty
Summary
The facility failed to ensure agency staff received the required communication training. During record review on 05/14/26, documentation could not be provided showing that agency CNA P, CNA Q, and LN K had completed the facility's communication training. During an interview later that day, Administrative Staff B stated she was responsible for scheduling agency staff and that the facility expected the agency to have already provided the required training and in-services to its staff before they were scheduled at the facility. The facility was also unable to provide a policy related to staff required in-services when requested.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide Communication training to five of five direct care staff members reviewed, including an LPN, three 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 the identified staff. The NHA later stated that the facility was unable to find any education records for those employees for the year 2025. The HR Director then confirmed that the facility failed to provide Communication training to five of five direct care facility staff. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of Licensee and 28 Pa. Code 201.20(a) Staff Development.
Missing Required Communication Training for Direct Care Staff
Penalty
Summary
The facility did not ensure that 5 of 5 direct care staff reviewed received the required communication training. The staff reviewed were CNAs TT, UU, VV, WW, and XX, all of whom had worked at the facility for longer than 1 year. The facility policy titled Training Requirements, last revised 1/1/25, states that training content includes effective communication for direct care staff and that documentation of required training is to be forwarded to HR for placement in the personnel file. On 5/4/26, the surveyor reviewed the records for the 5 CNAs and found the facility was unable to provide evidence that they had received the required communication training. On 5/5/26, the HR Director stated that HR handled new-employee onboarding but did not track annual trainings after hire, and that annual training should be kept track of by nursing. The HR Director also stated there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed the facility had no evidence of communication training being provided and stated training records were in boxes kept by the previous DON, with no organized system for employee trainings.
Incomplete Staff Training Documentation
Penalty
Summary
The facility failed to ensure all staff received mandatory training and education related to effective communication. The Facility Resident Census Roster and Facility Matrix/802 showed 83 residents resided in the facility. The facility assessment stated that the in-service training calendar included mandated annual training requirements and topics related to care and services for the identified population, but it did not include the amount of time or the types of training necessary to meet the effective communication training requirement. During interview, the Administrator stated that monthly staff meetings were used to provide in-service education and training, and that a monthly staff education tracking sheet listed topics covered and identified employees who attended if marked with an X. Review of the sheets showed no documentation of the subject matter covered. The Administrator also stated there was no agenda followed for the monthly in-services, that topics were provided according to a schedule, and that the in-services were done from memory. He further stated the facility did not have documentation of what educational material was presented at the monthly staff meeting and could not ensure each staff member received the training.
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