Inadequate Training and Inaccurate MDS Assessments
Summary
The facility failed to ensure staff responsible for participation in the MDS assessment process were adequately trained and competent to perform assigned duties in accordance with federal requirements and professional standards of practice. A review of the facility job description for the MDS Coordinator RN showed the role was responsible for coordinating completion of the resident assessment process and verifying interdisciplinary team members completed, dated, and signed assessments according to federal regulations. The report also noted that while an LPN may contribute to data collection and observation, the comprehensive nursing assessment and certification of the MDS require RN judgment and RNAC sign-off. Review of MDS assessments for six residents showed inaccuracies, with 14 of 15 identified errors involving Section GG Functional Abilities. The facility failed to accurately document the level of assistance residents required during the assessment look-back period, and the clinical record information did not match the MDS submissions. During interviews, the RNAC confirmed the assessments were not accurate, and an LPN assisting with the MDS process stated she was responsible for collecting data and observations for RNAC review but could not explain the discrepancies and reported she had not received sufficient training for her assigned duties. The RNAC stated the LPN had been identified as needing additional training, and the DON and NHA were unable to provide documentation showing the LPN had been trained in facility policies and procedures related to completion of the MDS assessment process.
Penalty
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The facility failed to maintain documentation showing that an SSA received required orientation, competency validation, and job-specific training. Review of the SSA’s file showed no training records after hire, and the DSD and ADMN confirmed that only verbal training had been provided and that no formal training plan was in place. The SSA stated he had very limited knowledge of his job duties and responsibilities.
Failure to maintain an effective staff training program was cited when the facility could not provide documented proof that a CNA completed required CEUs for certification renewal. CNA 3 said the hours were completed, but the DON could not verify several 2024 training records because signatures, attendance, topics, or proper documentation were missing, and the DSD stated the facility had no specific policy for maintaining in-service training records.
An LPN involved in a missing narcotics incident returned from suspension and worked a shift without documented education on drug diversion and narcotics reconciliation. The incident involved an Oxycodone IR 5 mg pack that appeared tampered with, with Loratadine tablets substituted for Oxycodone and five tablets missing. The DON and Staff Development/Educator acknowledged the education should have been completed before the LPN resumed work.
Missing Mandated Reporter Training Documentation: The facility failed to ensure an LVN completed Elder Abuse Mandated Reporter training and kept proof of that training in the personnel file. The DSD/LVN could not find any abuse training record in the file or electronic system, and the DON stated that without documentation there is no way to verify the training was completed. The facility policy required abuse, neglect, and exploitation training for new staff.
Missing EBP Competency Training for CNA and LVN: The facility failed to document EBP competency training for two staff members, a CNA and an LVN. Record review and interviews showed the IPN and DSD could not provide evidence that either staff member completed the required annual competency assessment or EBP training, and the facility policies required infection control competency and EBP training upon hire and at least annually.
The facility failed to document emergency preparedness training for a dietary server, a PTA, and a speech therapist. Records reviewed by surveyors did not show the required training for these staff members, and interviews with the DON and HRD confirmed gaps in the transcripts and uncertainty about completion for some employees. The facility policy stated that new and existing staff, volunteers, and contractors were to receive required training on key topics, including resident rights, abuse, dementia management, and infection control.
Missing Training Documentation for SSA
Penalty
Summary
The facility failed to develop, maintain, and implement an effective training program for an existing Social Services Designee/Assistant (SSA) because it was unable to provide documentation verifying that the SSA had completed the required competency validation or job-specific training. During concurrent interview and record review, the SSA’s employee file was reviewed and showed that the SSA was hired on 6/16/26, but there was no documentation of competency validation or job-specific training in the file. The Director of Staff Development stated that all staff were expected to receive appropriate orientation and training before performing job duties and that documentation of training and competency validation should be maintained in the personnel file. The DSD confirmed that the facility could not provide documentation of the SSA’s competency or job-specific training and stated she would attempt to locate the records by contacting the Administrator, who was the SSA’s direct supervisor and responsible for training. During interview and record review with the Administrator, the SSA’s file still contained no documentation of facility competency or job-specific training. The Administrator stated the facility was without a Social Services Director, that the SSA was the only staff member assigned to Social Services, and that she was providing oversight during the vacancy. The SSA stated he had very limited knowledge of his job duties and responsibilities and that he had not received proper training. The Administrator later stated the SSA had received only verbal training, that no documentation was maintained in the personnel file, and that the facility did not have a formal training plan for the SSA.
Failure to Maintain CNA Training Records
Penalty
Summary
The facility failed to maintain an effective training program for one of three sampled CNAs when it could not provide documented evidence that CNA 3 completed the required continuing education units needed to renew an active certification. During an interview, CNA 3 stated she had completed the 48 hours of CEU required for renewal, but the DSD could not find the in-services. During a concurrent interview and record review, the DON reviewed CNA 3’s training records from January 2024 through December 2024 and stated she was not able to verify some of the training records because CNA 3 either never signed, never attended the training, there was no proof CNA 3 completed it, the person giving the in-service did not write a topic, or CNA 3 did not fill it out properly. The DON stated the current DSD can only verify what she has. During a later interview, the DSD stated the facility is responsible for maintaining the training records and said the facility does not have a specific policy on maintaining in-service trainings, and she was unable to provide one. A review of the DSD job description showed that maintaining records of in-services was listed as an essential duty.
LPN Returned After Narcotics Incident Without Required Education
Penalty
Summary
Facility staff failed to implement an effective training program for existing staff when Employee #6, an LPN involved in a reported incident of missing narcotics, returned to work after suspension without documented education on drug diversion and narcotics reconciliation. A Facility Reported Incident documented a possible narcotics variance, and the follow-up report stated that Employee #6 found an Oxycodone IR 5 mg tablet difficult to remove from the pack, discovered the back of the pack had been tampered with and taped closed with clear tape, and found the Oxycodone tablet had been replaced with Loratadine tablets of similar color, size, and shape. The report also stated that five tablets were missing in total. Review of the employee’s timecard showed she worked the night shift after suspension, and review of education records showed no documented evidence that she had completed or received the required drug diversion/narcotics reconciliation education before returning to work. The DON and Staff Development/Educator acknowledged that the employee should have received the education prior to restarting work after suspension.
Missing Mandated Reporter Training Documentation
Penalty
Summary
The facility failed to ensure that one of one staff member, LVN 7, completed Elder Abuse Mandated Reporter training in accordance with the facility's policy and procedures titled Training Requirements. During a concurrent interview and record review of LVN 7's personnel file, the file did not contain evidence of Elder Abuse Mandated Reporter training upon hire. The Director of Staff Development/LVN 2 stated there was no Elder Abuse Mandated Reporter training in the staff member's file and, after checking the facility's electronic system, was unable to provide any additional information regarding abuse training for LVN 7. During interview, the DON stated that if the abuse training is not in the file, there is no way to verify that the training was completed. The DON further stated that the abuse training provided to new employees should remain in the file to prove they received the training needed to safely perform their duties for residents, and that without it, staff may not know what to do when working with residents. The facility's policy required training on abuse, neglect, and exploitation, including the types of actions that constitute abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property.
Missing EBP Competency Training for CNA and LVN
Penalty
Summary
The facility failed to ensure that two of three sampled staff members, CNA 3 and LVN 3, received enhanced barrier precautions (EBP) competency training. During a concurrent interview and record review, the Infection Preventionist Nurse was unable to provide documentation showing that either staff member had completed EBP training. During a later review with the Director of Staff Development, the Annual CNA Competency form for CNA 3 and the Initial/Annual License Nurse Competency form for LVN 3 were reviewed, and neither form indicated that EBP training had been completed. The facility’s policy titled Competency of Nursing Staff stated that competency skills include infection control and that competency evaluations are to be conducted upon hire, annually, and as necessary based on assessment. The policy titled Enhanced Standard/Barrier Precautions stated that staff are to receive EBP training upon hire and at least annually. The Infection Preventionist stated she did not have records showing that CNA 3 and LVN 3 completed annual competency assessments and evaluations, and the DON stated the facility was unable to locate documentation of their annual competency assessments and EBP training.
Missing Emergency Preparedness Training for Multiple Staff
Penalty
Summary
The facility failed to ensure that staff members #44, #168, and #182 received training on emergency preparedness. During review of staffing and transcript records on 5/28/2026, the emergency preparedness training was not listed for the Dietary Server, the Physical Therapy Assistant, or the Speech Therapist, and the records did not show when each staff member completed the annual training. The Dietary Server was hired on 12/16/2024, and the transcript history for 2025 did not show emergency preparedness training. The Physical Therapy Assistant was hired on 08/01/2024, and the transcript document did not list emergency preparedness training. The Speech Therapist was hired on 01/05/2026, and her 2026 transcript did not list emergency preparedness training; the transcript also showed other modules started on 03/30/2026, 04/01/2026, 04/22/2026, 04/23/2026, and 05/06/2026. During interviews, the DON stated that staff complete annual training through eCampus and weekly meetings, and that emergency preparedness training is included twice a year. The HRD stated that the facility expected contracted rehabilitation staff to receive the same training as facility staff, but he did not see emergency preparedness training listed for Staff #168 or Staff #182. The facility policy titled Staff Development and Orientation-Resident Care stated that all new and existing staff, volunteers, and contractors would receive training on resident rights, abuse, neglect and exploitation, dementia management, and infection control.
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