Deficiency in Staff Training Compliance Tracking
Summary
The facility was found to lack a system for tracking staff compliance with mandatory training, which could lead to inadequate staff competency and poor quality of care. During an interview, the Director of Staff Development (DSD) presented a binder of in-person training sessions provided over the last four months, including topics such as bowel & bladder, urinary tract infections, abuse, pressure injuries, and infection control. However, the DSD could not provide a clear method for tracking staff participation in these mandatory trainings, relying instead on staff to attend and follow up if they missed a session. Evidence was requested for five sampled Licensed Nurses, but the DSD could only provide online training records for four of them, with no evidence for the fifth nurse, Licensed Staff H, regarding specific trainings. Further investigation revealed inconsistencies in the training records. The Administrator was asked to provide a list of annual mandatory trainings and evidence of completion by night shift staff. The records showed that some mandatory trainings were overdue by several years, and some staff had not received required refresher courses. The facility's job description for the DSD emphasized the responsibility to ensure all educational programs comply with applicable standards to maintain high-quality resident care, highlighting a significant gap in the facility's training compliance and tracking system.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Lack of PICC Line Training and Competency Validation: The facility failed to maintain an effective staff development program to ensure LPNs had documented education and competency for PICC line care. Two residents had PICC lines for antibiotic therapy, and agency LPNs accessed the lines to provide NS flushes and IV antibiotics. Records showed no PICC-specific training or competency validation for the LPNs, and the RA confirmed no structured PICC line training program existed for agency licensed nurses.
The facility failed to implement and complete its nurse orientation and competency validation process for new LPNs, resulting in two separate medication errors. One LPN, new to LTC and unfamiliar with the facility’s computer system, was left alone on the med cart after only partial observation-based training and without a completed competency checklist, and a resident received another resident’s medications. Another new LPN, also without documented competency sign-offs, was in joint med-pass with an untrained preceptor when a resident requesting pain medication was given sleeping pills after the preceptor pulled the wrong controlled medication and the trainee administered it. Preceptors were selected informally from floor nurses without preceptor training, and leadership interviews confirmed that required competency checklists and the facility’s own med-pass orientation policy were not consistently followed or documented.
The facility did not maintain an effective training program for new and existing staff, as confirmed by record review and interviews with the Administrator and a regional clinical leader. Available in-service records showed training only on QAPI, infection control, resident rights, and abuse, with no documented training on communication, behavioral health, compliance and ethics, or required annual nurse aide education. The Administrator acknowledged that staff had not been trained on these topics, that CNAs had not received their required annual training hours, and that there was no facility policy governing staff training. This deficiency had the potential to affect all 67 residents in the facility.
Inadequate Training and Inaccurate MDS Assessments: The facility failed to ensure staff assisting with the MDS process were adequately trained and competent to complete assigned duties. MDS reviews for several residents contained inaccurate Section GG Functional Abilities data that did not match the clinical record or the level of assistance documented during the look-back period. The RNAC confirmed the errors, and an LPN assisting with data collection stated she had not received sufficient training for her role; the DON and NHA could not provide documentation of training in MDS policies and procedures.
Staff training requirements were not fully completed for 2 employees reviewed, including an Activity Director and a Dietary Manager. Record review showed missing on-hire training in areas such as effective communication, HIV, dementia, infection control, restraint reduction, falls, and behavioral health. HR said she was new to the role and was not aware the required new hire training had not been completed, while the Administrator and DON stated they were responsible for ensuring required orientation and annual training were completed.
Incomplete staff training records showed multiple employees lacked required education in Infection Control, Abuse & Neglect, Fall Prevention, HIV, and Restraint Reduction. Record review found that several leaders and direct care staff, including the ADMIN, DON, ADON, LVN, CNA, and others, had missing training entries, while interviews showed staff believed their training was current and that education oversight had been inconsistent.
Lack of PICC Line Training and Competency Validation
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for licensed nursing staff to ensure they had the knowledge and competencies needed to safely manage PICC lines for two residents. The report states that federal requirements call for staff training based on the facility assessment, and Pennsylvania nursing regulations require nurses performing IV therapy, including PICC line care, to complete appropriate education, supervised clinical instruction, and ongoing competency validation. The facility policy on administration of medication or flush through a central venous line also stated that the procedure is complex and requires necessary education, training, and experience. One resident was admitted with a PICC line for antibiotic administration, and physician orders required routine flushing of the line with 10 mL of normal saline. The eMAR showed two agency LPNs repeatedly accessed the PICC line to administer normal saline flushes on multiple occasions in February 2026. Another resident was admitted with a PICC line for antibiotic therapy related to chronic multifocal osteomyelitis, and physician orders required the line to be flushed with 10 mL of normal saline before and after medication administration and during the day and evening shift. The March 2026 eMAR showed an agency LPN accessed the PICC line to administer flushes and IV antibiotics, including Ampicillin Sodium and Ceftriaxone Sodium. Employee personnel records showed no documented education, training, or competency validation related to PICC line management for either agency LPN. The report also states there was no evidence that the facility or contracted agency provided a structured training program, competency validation, or ongoing education specific to PICC line care for licensed nursing staff. During interview, the Regional Administrator of Clinical Operations confirmed the facility could not provide documentation of PICC line-specific training or competency validation and had not developed or implemented a training program specific to PICC line management for agency licensed nurses.
Failure to Implement Effective Nurse Orientation and Competency Validation Leading to Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective nurse training and competency program for new LPN staff, resulting in incomplete orientation and unverified competencies for at least two nurses. The facility maintained a New Trainee Folder and a Licensed Nurse Competency Skills Check-off form intended to cover unit safety, communication, infection control, nursing care, emergency procedures, equipment, medication administration, pain management, resident rights, abuse, dementia care, QAPI, person-centered care, cultural competency, and HIPAA. Human Resources reported that the competency checklist was to be printed and placed in a staffing binder, completed by the preceptor over the first three days, and then signed off by leadership. However, for both reviewed LPNs, these competency checklists were not completed, and there was no documented verification that they had met medication administration or other required competencies before functioning independently. One LPN, on her first day working in the facility and with no prior LTC experience, was involved in a medication error in which a resident received another resident’s medications. This LPN reported that she had only been trained by an RN from 6 AM to 10 AM on how residents took their medications and who had swallowing issues, and that she did not know how to enter orders into the computer system and was unfamiliar with the software. The RN preceptor stated that the LPN had only observed her and had not performed any tasks independently before the RN left, and that she had not checked the LPN off to administer medications alone. The Unit Manager acknowledged that the LPN had no LTC experience, that she did not complete the medication portion of the competency checklist, and that she left the LPN alone on the cart after the LPN stated she felt comfortable, despite not having seen her pass medications. The facility’s Medication Administration policy required that new personnel not administer medications until oriented to the system and that a charge nurse accompany them on medication rounds for a minimum of three days, but this process was not followed or documented for this LPN. Another new LPN, also without a completed competency checklist, was involved in a separate medication error in which a resident requesting pain medication received sleeping pills instead. This LPN reported that she was in training with a preceptor, and that both nurses were pulling medications from the same cart, with the preceptor handling controlled substances. The error occurred when the preceptor punched a sleeping pill from the wrong card, and the trainee LPN administered it, noting that the pills were both small and white and that they were trying to hurry. The LPN stated she did not recall any specific competency check-offs being done beyond a license check. The Unit Manager and ADON both confirmed that preceptors were simply floor nurses who had been at the facility longer, with no formal preceptor training, and that the current training program had only recently started. Employee files for both LPNs lacked completed Licensed Nurse Competency Skills Check-off forms as of the survey date, and leadership interviews showed uncertainty about when competency checklists should be completed and how much training the LPNs had actually received before being allowed to function independently.
Failure to Provide Required Staff Training on Communication and Behavioral Health
Penalty
Summary
The facility failed to ensure staff were trained on effective communication and other required topics, affecting all 67 residents in the building. During review of staff in-service records on 3/24/26 at 11:00 AM, the surveyor and the Administrator (V1) identified that training subjects such as communication, behavioral health, and required annual nursing aide training were missing. At 12:50 PM, the Regional Director of Clinical Services (V7) confirmed he could only locate staff training on QAPI, infection control, resident rights, and abuse, and that he was unable to find any staff training on communication, compliance and ethics, behavioral health, or any required nursing aide training. At 1:00 PM, the Administrator acknowledged that staff had not been trained on communication or behavioral health and that nurse aides had not received their required annual training hours, stating she was not aware these were required. On 4/13/26 at 3:00 PM, the Administrator further stated that the facility did not have a policy related to staff training. The facility’s daily census report dated 3/17/26 documented 67 residents residing in the facility. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency were provided in the report.
Inadequate Training and Inaccurate MDS Assessments
Penalty
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.
Staff Training Program Not Completed for New Hires
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for 2 of 17 employees reviewed for training requirements: the Activity Director and the Dietary Manager. Record review showed the Activity Director was hired on 04/01/2026 and did not have evidence of on-hire training in effective communication, HIV, dementia, infection control, or restraint reduction. Record review also showed the Dietary Manager was hired on 03/10/2026 and did not have evidence of required training on falls, dementia, infection control, or behavioral health on hire. During interviews, the HR staff member stated she was new to her position and was responsible for completing orientation and paperwork, but was not aware that new hire training had not been completed as required for all employees. The Administrator stated staff were initially trained by logging into a website and watching training videos that included abuse/neglect, blood borne pathogens, HIV, misuse of resident property, resident rights, behavioral health, effective communication, dementia, and fall prevention, and said she was ultimately responsible for ensuring required training was completed during orientation, prior to employment, and annually. The DON stated she was responsible for ensuring nursing staff received required training during orientation, prior to employment, and annually.
Incomplete Staff Training Records
Penalty
Summary
The facility failed to maintain an effective training program for multiple existing staff members after record review showed missing required education in several areas, including Infection Control, Abuse and Neglect, Fall Prevention, HIV, and Restraint Reduction. Personnel files reviewed on 3/23/2026 and 3/24/2026 showed that 14 of 16 staff members had incomplete training records in one or more required topics, including the ADMIN, DON, SW, AD, DM, MS, ADON, LVN A, CMA C, CNA E, CNA B, LA F, HK G, and TA D. The record review identified that the ADMIN had not completed Infection Control, Abuse & Neglect, and HIV training; the DON, SW, AD, DM, MS, ADON, CMA C, HK G, and TA D had not completed HIV training; LVN A had not completed Fall Prevention, HIV, and Restraint Reduction training; CNA B had not completed Infection Control, Fall Prevention, and HIV training; CNA E had not completed Restraint Reduction training; and LA F had not completed HIV and Restraint Reduction training. The facility’s 2025 calendar showed monthly education topics assigned for Infection Control, Resident Abuse Prevention, Restraints, HIV Education, and Fall Prevention. During interviews, LVN A stated she thought her trainings were up to date but said the facility used several different computer-based training sites and it was hard to keep up with them. CMA C stated training was done online and she believed she was up to date, and no staff had told her about any recent training that was due. The CCO stated some training courses had not been completed and were out of compliance, that she had just taken over responsibility for ensuring education was current, and that HIV training had not been recognized as a separate requirement. The DON stated there were three staff responsible for education oversight and that HIV education had been overlooked.
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