Missing QAPI Training and Incomplete Annual Staff Education
Summary
The facility did not ensure that all new and existing staff received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program as part of its overall education program. During the recertification and extended survey, surveyors reviewed the facility assessment and the QAPI policy and found that the facility assessment listed multiple staff training and competency topics, but QAPI policy and procedures were not included in the required education topics. The QAPI policy, which was undated, also did not document a requirement that staff be educated on the QAPI policy. Record review of five employee files showed that required annual education was not consistently completed or documented. A CNA file showed no documented evidence that annual education had been completed after 1/09/2022, and the electronic record showed less than 12 hours of annual education. Another CNA file contained multiple sign-in sheets and posttests, but it could not be determined whether all required annual education had been completed, and the electronic record also showed less than 12 hours completed. A third CNA file had no evidence of annual education except for a written statement about verbal education related to an incident, and no education topics were listed in the electronic record. An LPN file showed no documented annual education since 2022 except for one posttest and part of an untitled answer sheet, and the electronic record showed only two of ten education topics completed for 2025. Another LPN file showed no documented annual education since 2024, and the electronic record showed only one of six education topics completed for 2025. Interviews with facility leadership and staff showed that education practices were inconsistent and dependent on who was available. An assistant administrator stated that education was often done on the spot when needed, that education stopped for a period during staff changes, and that records from the prior ADON could not be found. A nurse stated they knew they had overdue education in the electronic system and were unsure whether they had received QAPI teaching. The DON stated education was a priority and identified several required annual topics, while the administrator stated the online education system tracked required hours and that house-wide education included topics such as fire safety, resident rights, abuse, and oxygen control. The report also states that QAPI was not part of nursing education.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing QAPI Training for CNAs: Mandatory yearly QAPI in-service training was not documented for 5 sampled CNAs. The facility assessment listed several yearly staff training topics and competencies, but QAPI was not included in the training plan. The NHA confirmed CNAs are required to complete yearly in-service hours and stated CNA training should include QAPI, though the facility does not provide training directly titled QAPI.
Failure to Provide Required QAPI Training to Nurse Aides: Five of five nurse aides reviewed did not complete annual QAPI education. Personnel records and continuing education transcripts showed no QAPI training for each aide, and the NHA confirmed the missing training during interview. The job description required staff to complete assigned education and training as required by law or regulation.
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.
An LPN did not receive required QAPI training during the past year of employment. Review of the personnel and training records showed no documentation of QAPI education, and the IP confirmed the missing training for one of five direct care staff reviewed.
Mandatory QAPI training was not documented for 2 of 2 non-direct staff reviewed. Housekeeper-PP and Cook-QQ had records for resident rights, abuse/neglect/exploitation, infection control, and compliance & ethics, but surveyors could not locate QAPI training in their files. The NHA, DON, and Senior VP of Clinical Compliance & Quality discussed how in-services are assigned, and the Senior VP later stated QAPI training was not available for these staff.
Mandatory QAPI training was not documented for five of five employees reviewed, including a dietary manager, CNAs, a housekeeping aide, and a contracted travel LPN. The DON said staff were informed about PIPs through department managers but did not receive training on the elements and goals of the QAPI program. The HR director said QAPI training had not been assigned and was not recognized as required, and the CEO acknowledged required training was incomplete. The facility policy required ongoing education for personnel, but QAPI was not listed as required training.
Missing QAPI Training for CNAs
Penalty
Summary
Mandatory yearly QAPI in-service training was not included for 5 of 5 randomly sampled CNAs: CNA J, CNA K, CNA L, CNA M, and CNA N. The facility assessment, last reviewed 1/2026, stated that staff would receive training and education upon hire, yearly, and as needed, and listed topics such as communication, resident rights, abuse, infection control, and culture change, along with competencies including person-centered care, ADLs, disaster, infection control, and caring for persons with Alzheimer's or another dementia. Surveyor review noted that QAPI training was not included in the facility's training plan. During interview on 7/02/26, the NHA stated that CNAs are required to complete 12 hours of yearly in-service/education and confirmed that CNA yearly training should include QAPI. The NHA also stated the facility does not provide training directly titled QAPI, but instead presents interventions and actions put in place for issues identified. Review of the Nurse Aide In-Service Records for CNA J, CNA K, CNA L, CNA M, and CNA N showed they did not receive documented mandatory yearly QAPI in-service training.
Failure to Provide Required QAPI Training to Nurse Aides
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not provided to five of five nurse aides reviewed: Nurse Aides 6, 7, 8, 9, and 10. Review of the nursing assistant job description showed that nurse aides were required to complete or attend all training and education as assigned and as otherwise required by applicable law, rule, or regulation. Personnel records showed Nurse Aide 6 was hired on February 19, 2019; Nurse Aide 7 on August 21, 2017; Nurse Aide 8 on November 23, 2012; Nurse Aide 9 on June 24, 2021; and Nurse Aide 10 on November 7, 1995. Review of each nurse aide’s continuing education transcript showed no annual education regarding QAPI training. The Nursing Home Administrator confirmed in an interview on June 16, 2026, at 2:27 p.m. that Nurse Aides 6, 7, 8, 9, and 10 did not complete the required QAPI education. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(a) Staff Development.
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
Mandatory training on the facility’s QAPI Program was not provided to one of five direct care staff reviewed, an LPN identified as Employee E7. Review of the personnel file showed the LPN was hired on 8/1/24, and review of the education training records on 6/3/26 showed no documentation of QAPI education during the past year of employment as required. During an interview on 6/3/26 at 10:30 a.m., the Infection Preventionist, Employee E16, confirmed that the facility failed to provide QAPI training to one of five direct care facility staff.
Failure to Provide QAPI Training to Non-Direct Staff
Penalty
Summary
Mandatory training on the facility’s QAPI Program was not provided to 2 of 2 non-direct staff reviewed. Housekeeper-PP, hired 3/28/25, had training records showing resident rights and responsibility, abuse, neglect, exploitation, infection control, and compliance & ethics, but surveyor was unable to locate any QAPI training. Cook-QQ, hired 4/27/21, also had records showing resident rights and responsibility, abuse, neglect, exploitation, infection control, and compliance & ethics, but surveyor was unable to locate QAPI training in the 2025-2026 training records. On 6/3/26, the surveyor requested training records for Housekeeper-PP and Cook-QQ and later met with the NHA-A, DON-B, and Senior VP of Clinical Compliance & Quality-VV to ask how in-services are assigned and who is responsible for training non-nursing staff. NHA-A stated in-services are assigned monthly and additional training is assigned as needed, and that she provides one-on-one or shift-to-shift training with other departments along with department heads. Senior VP of Clinical Compliance & Quality-VV stated employee training is through the support center compliance department for required trainings, and later informed the surveyor that QAPI training was not available for Housekeeper-PP and Cook-QQ.
Missing QAPI Training for Newly Hired and Contracted Staff
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program was not provided to five of five employees reviewed: dietary manager G, CNA O, contracted travel CNA Z, housekeeping aide Y, and contracted travel LPN R. Personnel record review showed these employees were hired between 7/28/25 and 4/27/26, and there was no documentation that they received training on the elements and goals of the facility’s QAPI program. Interviews confirmed the training gap. The DON stated she managed QAPI meetings and that staff were informed about performance improvement plans through their department manager, but staff did not receive training on the elements and goals of the QAPI program. The HR director stated she was responsible for assigning required staff training, but QAPI training had not been assigned and she was not aware it was a required topic. The CEO acknowledged that required training had not been completed. The facility’s August 2018 Required Annual Training of Long-Term Care Healthcare Workers policy stated training was to be completed in accordance with state and federal regulations and that the provider would maintain a formal orientation program and ongoing education program for all personnel; however, QAPI elements and goals were not listed as required staff training in the policy.
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