Deficiency in Staff Training Program
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, affecting 17 employees reviewed for training requirements. The deficiency was identified through interviews and record reviews, revealing that the facility did not provide mandatory annual training on various essential topics such as Communication, Residents Rights, Quality Assurance and Performance Improvement (QAPI), Infection Control, Ethics, Behavioral Health, HIV, Falls, and Restraints. This lack of training was evident across multiple staff roles, including Cooks, Maintenance, Admissions, Certified Nursing Assistants (CNAs), Medication Aides, Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), and administrative staff. Personnel records showed that employees hired as far back as 1996 and as recently as 2023 had not received the required annual training. For instance, a CNA hired in 2010 had no evidence of training in Communication, QAPI, Behavioral Health, HIV, and Restraints. Similarly, a Med Aide hired in 2022 lacked training in Dementia, QAPI, Behavioral Health, and Falls. The HR Manager, responsible for assigning these trainings through an online system, acknowledged the oversight, attributing it to a challenging year. Interviews with the HR Manager and the Administrator highlighted the importance of these trainings in ensuring residents receive proper care and are protected from poor treatment, abuse, and neglect. The facility's policy on in-service training, dated August 2022, outlined the required training topics and emphasized the necessity of completing these trainings before staff provide services to residents and annually thereafter. However, the facility failed to adhere to these policies, as evidenced by the lack of documented training across the reviewed personnel records.
Penalty
Resources
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The facility failed to maintain an effective QAPI training program for all staff, as evidenced by missing QAPI content in orientation materials, use of an outdated annual education calendar without QAPI, and lack of documented QAPI education for sampled RNs, an LPN, and CNAs. The staff development coordinator reported she did not provide QAPI training and believed it was handled by HR, while the HR director confirmed QAPI was not included in new-hire orientation. Limited computer-based QAPI training records showed only some employees from various disciplines had completed QAPI modules, with no clear evidence that all staff were trained or that training was updated after new QAPI goals were set.
Missing QAPI Training for Five Staff Members: The facility failed to provide annual QAPI in-service training for five staff members, including two NAs, an RN, and an LPN. Personnel files did not show credible QAPI training for the review period, and the NHA confirmed the lapse during interview.
Mandatory QAPI training was not completed for an RN, an LPN, and four NAs reviewed for training requirements. The facility assessment stated all staff were to receive QAPI training, but the administrator confirmed the RN and LPN had not completed it and further review showed the four NAs also had not completed the training. The administrator stated QAPI training was not completed at orientation and was done through the online training program.
Failure to provide required QAPI training for five staff members, including an LPN, an RN, and three NAs. Facility policy required all staff to complete regular in-service education on QAPI, but personnel files showed no annual QAPI training for the review period, and the NHA confirmed there was no employee education for the year reviewed.
Surveyors found that required Quality Assurance and Performance Improvement (QAPI) training was not completed by a CNA, a dietary staff member, and a housekeeping staff member, despite facility policy and the facility assessment requiring all staff, including contracted personnel and volunteers, to receive annual education on QAPI basics and the elements and goals of the QAPI program. The SDC reported that education was assigned via an annual competency calendar and that she was working on catching up missed education and arranging training for contracted staff, but could not provide documentation that these three employees had completed the required QAPI training.
The facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to its staff. Review of the annual in-service schedule and staff in-service and computer-based training records over more than a year showed no QAPI-related education. The census documented 87 residents in the facility, and the Administrator in Training confirmed that staff had not received QAPI training, potentially affecting all residents.
Failure to Maintain Effective QAPI Training Program for Staff
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and maintain an effective training program for all staff on its Quality Assurance and Performance Improvement (QAPI) program. During an extended survey triggered by findings of substandard quality of care, surveyors determined that required QAPI training was not consistently provided to staff, including RNs, LPNs, and CNAs. Interviews with staff and review of training records for five sampled nursing staff members showed no documentation of QAPI education, and those staff members reported they could not recall receiving such training. The facility’s orientation materials, which covered topics such as employee benefits, health and safety, resident rights, infection control, and competencies, did not include QAPI. The Staff Development Coordinator stated she did not provide QAPI training and believed it was handled by Human Resources, while the Human Resources Director confirmed that QAPI was not part of new-hire orientation. The annual education calendar used by the Staff Development Coordinator was from 2017 and did not list QAPI as a topic. Later, the Staff Development Coordinator produced limited documentation of computer-based QAPI training, showing that 14 employees from various disciplines received QAPI in-service education in one month and that 117 employees had completed QAPI training assigned on a prior date; however, she was unsure if this list included all employees. There was no evidence of ongoing QAPI training after new QAPI goals were established, and no additional education documents were available for the sampled staff.
Missing QAPI Training for Five Staff Members
Penalty
Summary
Conduct mandatory training for all staff on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not completed for five of five staff members. Review of the facility’s In-Service Training Program policy showed that nurse aide personnel are to participate in regularly scheduled in-service training classes and that training attendance is to be recorded on each employee’s Record of In-Service. However, review of personnel files showed no credible annual in-service training on QAPI for NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8 for the 1/1/25 through 12/31/25 period. The personnel records identified the employees’ dates of hire as 3/20/24 for NA Employee E4, 10/22/19 for NA Employee E5, 5/30/19 for RN Employee E6, 10/19/15 for LPN Employee E7, and 3/9/81 for NA Employee E8. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide QAPI training for these five staff members.
Failure to Complete Required QAPI Training for Multiple Staff
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not completed for 6 of 10 staff reviewed, including an RN, an LPN, and four NAs. The facility assessment dated [DATE] stated that the facility had developed a training program with orientation and ongoing training for all new and existing staff, and that all staff were to receive QAPI training. During interviews, the administrator stated she was responsible for overseeing and ensuring staff completed required training. On follow-up review, the administrator confirmed that QAPI education was not found in the personnel files provided for the RN and LPN and verified those trainings had not been completed. The administrator also stated that QAPI training was not completed at orientation and was instead completed through the online training program. Further review showed that training had not been completed for the four NAs, and a facility policy regarding required staff training was requested but not received.
Failure to Provide Required QAPI Training
Penalty
Summary
The facility failed to provide required annual in-service training on the Quality Assurance and Performance Improvement (QAPI) program for five of five staff members reviewed: one LPN, one RN, and three NAs. Facility policy titled In-Service Training, All Staff, dated 2/11/26, stated that all staff are required to participate in regular in-service education and that required topics include the elements and goals of the facility QAPI program, with training to be completed before staff provide care, annually, and as needed based on the facility assessment. During interviews, the NHA stated that the facility had recently made everyone complete education and later stated there was no employee education for 2025 because the previous HR employee did not do the job correctly and the outgoing corporate company was not monitoring the work. Review of the personnel files for the five staff members showed education test packets dated in March 2026, but no annual in-service training on the QAPI program from 1/1/25 through 12/31/25. For one NA, the education packets were signed but undated. The NHA confirmed that the facility failed to provide QAPI training for these five staff members.
Failure to Ensure Required QAPI Training for All Staff
Penalty
Summary
Facility staff failed to ensure completion of required Quality Assurance and Performance Improvement (QAPI) training for multiple employees. During a survey, review of staff records showed that a CNA, a dietary staff member, and a housekeeping staff member had no documented evidence of having completed QAPI training. The facility’s own assessment, reviewed in late February 2026, specified that all staff annual education topics included “QAPI Basics,” and the written policy on in‑service training for all staff, dated 2001, required all new and existing personnel, contracted service providers, and volunteers to participate in regular in‑service education, including training on the elements and goals of the facility’s QAPI program. In an interview, the staff development coordinator (SDC) reported that she began working at the facility in December 2025 and that there was an annual competency calendar assigning education throughout the year, with staff having until the end of the year to complete their assignments. She stated she had an ongoing performance improvement plan to catch up on missed education, including efforts to obtain education for contracted staff such as therapy and dietary personnel, but this work was not yet completed. When surveyors requested evidence of QAPI training completion for the identified CNA, dietary staff member, and housekeeping staff member, none was provided. The administrator, DON, and other regional and clinical leaders were informed of the concern, and no additional information was submitted before survey exit.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to all employees as required. Record review showed that the Midnight Census Report dated 3/24/26 documented 87 residents residing in the facility. Review of the facility’s Annual In-Service Schedule revealed that it did not include any in-servicing regarding QAPI. Additionally, review of Staff In-Services and Computer Based Training records dated from 3/1/25 through 3/28/26 showed no evidence that QAPI training had been provided. On 3/28/26 at 9:50 AM, the Administrator in Training confirmed that facility staff had not received QAPI training. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency, only that all 87 residents had the potential to be affected.
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