Failure to Track and Document Required Annual Staff In-Service Training
Summary
The facility failed to ensure staff training needs identified in the facility assessment and annual in-servicing calendar were met for five of five staff reviewed. The facility also failed to maintain documentation that staff completed 12 hours of annual in-service training. The census was 83. During interview, the Administrator stated the facility did not have a policy addressing 12 hours of annual training. Review of the Facility Assessment Tool dated 07/20/25 showed required in-service training topics included communication, resident rights and facility responsibilities, abuse, neglect and exploitation, infection control, culture change, dementia care, caring for the cognitively impaired, changes in condition, cultural competency, person-centered care, activities of daily living, disaster planning and procedures, medication administration, measurements, resident assessment and examinations, caring for residents with Alzheimer's, caring for residents with mental and psychosocial disorders, and specialized care. The facility's Education Calendar listed monthly topics such as incident/accident prevention, resident rights, infection control, emergency preparedness, body mechanics, dementia care, abuse/neglect, restorative care, and compliance/ethics, but it did not address person-centered care, measurements, resident assessment and examinations, or caring for residents with mental and psychosocial disorders. Review of the education binder showed multiple in-services were provided in 2025 and 2026, including infection control, reporting abuse and neglect, death and dying, customer service, fall prevention, de-escalation of behaviors, resident rights, privacy and dignity, and contact precautions. The record contained sign-in sheets, but the hours of each in-service were not documented, and the binder did not show evidence that the facility covered the topics identified on the Facility Assessment Tool or the Education Calendar. Five CNAs reviewed had no documentation of receiving 12 hours of annual in-service training, and one CNA stated he/she did not regularly attend in-services, did not know when they were held, and did not know he/she was required to attend 12 hours each year covering specific LTC care topics.
Penalty
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The facility failed to maintain an in-service training program for CNA staff with the required topics and at least 12 hours per year. Review of five staff files showed missing annual training hours, and several staff lacked required dementia education; one CMA also lacked training on abuse, neglect, and exploitation. Administrative Staff A stated that CNAs were expected to have the required training, and no staff training policy was provided.
Five of five sampled CNAs did not have documented annual in-service education totaling 12 hours, and their records did not include dementia management or abuse prevention training. The facility assessment listed abuse and caring for persons with dementia among required training topics, and the NHA agreed the CNA in-service records did not meet the yearly hour requirement and should include dementia and abuse education.
The facility failed to provide documentation showing that one CNA completed the required 12 hours of annual in-service education. During record review, the prior year's training was requested, and the ACNO stated she could not provide proof of the CNA's 12-hour annual training.
Missing Annual Dementia Training for CNAs: The facility failed to ensure all CNAs received the required five hours of annual dementia training. The DSD confirmed only one hour of dementia training had been provided within the last year, while the ADON and ADM stated the training was mandatory for all staff. Facility policy required dementia-specific caregiver training at five hours per year for CNAs and for staff training records to be maintained.
Four CNAs did not have documentation of required annual dementia training. Record review showed CNA-Q, CNA-R, CNA-S, and CNA-V lacked evidence of completing the dementia training required by the facility assessment and competency policy. HR could not locate the records, and the NHA stated the facility was unable to find additional training documentation for those staff.
The facility failed to ensure that one of two nurse aides received the required 12 hours of annual in-service education. The NHA stated that education is distributed electronically for completion during the calendar year, but the employee file for one nurse aide did not show the required yearly training for the prior year, and the NHA confirmed the lapse.
CNA In-Service Training Deficiencies
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for CNA staff that included the required topics and at least 12 hours per year. Review of five CNA personnel files showed that CNA N, hired on 04/04/2007, lacked the total hours required for the 12-hour annual training. CMA T, hired on 12/20/2012, also lacked the total required hours and did not have education on abuse, neglect, exploitation, and dementia. CNA MM, hired on 03/25/2023, lacked the total required hours and did not have dementia training. CNA M, hired on 03/07/2024, lacked dementia training. CNA O, hired on 02/12/2025, lacked the total required hours and did not have dementia training. On 07/08/2026 at 10:00 AM, Administrative Staff A stated that she expected CNAs to have the required 12 hours and required training completed, and the facility did not provide a policy for staff training.
CNA Annual Training Records Lacked Required Hours and Dementia/Abuse Content
Penalty
Summary
Nurse aide continuing competence was not ensured because 5 of 5 randomly sampled CNAs—CNA J, CNA K, CNA L, CNA M, and CNA N—did not have documented yearly in-service education totaling at least 12 hours, and their records did not include dementia management training or resident abuse prevention training. The facility assessment, last reviewed in 1/2026, stated that staff training and education would be provided upon hire, routinely on a yearly basis, and as needed, and it listed abuse and caring for persons with Alzheimer's or another dementia among the training and competency topics. During interview on 7/02/26, the NHA stated that CNAs are required to receive 12 hours of yearly in-service education and agreed that the reviewed Nurse Aide In-Service Record sheets for the five CNAs did not meet that requirement; the NHA also indicated that yearly in-service education should include dementia and abuse training.
Missing Annual CNA In-Service Training Documentation
Penalty
Summary
The facility failed to provide a minimum of 12 hours of annual in-service education for 1 of 5 CNAs reviewed, CNA #2. During record review on 6/25/26, the prior year's in-service training was requested for CNA #2, and at 4:12 PM the ACNO stated she was unable to provide documentation of CNA #2's 12-hour annual training.
Missing Annual Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Aides (CNAs) received the mandatory five-hour annual dementia management training. During a concurrent interview and record review with the Director of Staff Development, CNA trainings and the annual 2026 mandatory in-service calendar were reviewed, and the DSD stated that staff are to be provided with five hours of dementia training annually. The DSD stated that only one hour of dementia training had been provided within the last year and that dementia training was important to ensure staff are equipped with the knowledge and skills needed to care for residents with cognitive concerns. During interviews, the Assistant Director of Nursing and the Administrator both stated that dementia training was mandatory and that all staff must complete five hours annually. The ADON stated dementia residents were at risk to be mistreated and neglected when staff are not educated on how to provide care. Review of the facility policy titled Facility Inservice Education Program indicated that each employee will have an educational profile completed at hire and annually, the Staff Development Department will maintain records of in-services attended, and dementia-specific caregiver training is required at five hours per year for CNAs.
Missing Annual Dementia Training for CNAs
Penalty
Summary
The facility did not ensure that 4 of 5 CNAs completed the required annual dementia training. During interview and record review, CNA-Q, CNA-R, CNA-S, and CNA-V were found to have no documentation showing completion of the required dementia training. The facility assessment documented that nurse aide in-service training must be sufficient to ensure continuing competence and must include dementia management training and resident abuse trainings. The facility policy on competency evaluation stated that employee competencies and skills are to be evaluated and documented through training checklists and competency forms maintained by the staff development coordinator and then forwarded to HR for the employee file. On 6/3/26, the surveyor reviewed annual employee training records and found no evidence that the four CNAs had completed the required dementia training. HR-D stated they were not aware dementia training was required and could not locate records for the four CNAs. NHA-A stated mandatory trainings are tracked by the facility and also could not locate additional training records for those staff.
Nurse aide annual in-service training not completed
Penalty
Summary
The facility failed to ensure that all nurse aide staff received a minimum of 12 hours of in-service education training each year for one of two Nurse Aide employees, Employee E19. Review of the Nursing Assistant - HC Position Description showed that nurse aides are expected to maintain compliance with yearly education requirements according to facility policies and DOH regulations and to maintain competencies and skills through continued education, including in-service education, programs, floor conferences, and nursing staff meetings. During an interview, the Nursing Home Administrator stated that education is distributed electronically to be completed within the calendar year from January through December. Review of Employee E19's current employee file did not show that the employee had received the required minimum of 12 hours of yearly in-service training for calendar year 2025, and the Nursing Home Administrator later confirmed that the facility failed to ensure that all nurse aide staff received the required annual in-service education for Employee E19.
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