Lack of EBP Training and Policy in Facility
Summary
The facility failed to maintain an effective infection control training program for all 94 staff members by not developing a written policy and training regarding Enhanced Barrier Precautions (EBP). EBP involves the use of gowns and gloves during high-contact resident care activities to reduce the spread of infections. During an observation, it was noted that there was no personal protective equipment (PPE) cart or EBP signage by the door of a resident's room who had unstageable pressure injuries. Interviews with various staff members, including the Interim Infection Preventionist, Registered Nurse, Psychiatric Technician, RN Shift Lead, Supervising RN, and Nursing Coordinator, revealed a lack of awareness and training on EBP. The staff admitted to not using gowns during wound care and were unaware of the EBP guidelines. The facility was unable to provide a policy for EBP upon review, and staff interviews confirmed that no training had been conducted. The Interim Infection Preventionist and other staff members acknowledged that they were not up to date with EBP and that the facility's policy did not address it. The lack of training and policy on EBP had the potential to negatively affect the facility's ability to maintain a safe environment and prevent the spread of infectious diseases among the 54 residents in the facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Required Infection Control Training: The facility failed to provide annual Infection Control in-service training for five staff members, including NAs, an RN, and an LPN. Personnel files did not show credible training for the review period, and the NHA confirmed the missing training during interview. The facility policy required regularly scheduled in-service classes and documentation of attendance.
Missing Infection Control Training for Multiple Staff: The facility failed to provide required infection prevention and control training for 9 of 17 direct care staff reviewed, including CNAs, LVNs, the Dietary Manager, the Activity Director, and the ADON. Record review showed no evidence of initial hire training for several employees and no annual training for one CNA. Interviews with the ADON, HR, Administrator, and DON confirmed the training was not completed as required, despite a facility policy requiring initial orientation and in-service training on infection prevention and control standards, policies, and procedures.
Failure to Provide Required Infection Control Training: The facility did not provide required Infection Control in-service training for an LPN, an RN, and three NAs. The facility’s policy required regular staff education on infection prevention and control, but personnel files showed no annual Infection Control training for the affected staff, and the NHA stated there was no employee education for the prior year.
The facility failed to provide evidence of required infection control training for one staff member, a speech and language pathologist, during review of staff records. HR stated that new hires receive required trainings through a third-party provider and that completed trainings are transferred into another software, but she does not personally verify which trainings are required by regulation. Facility documents reviewed included onboarding training for Understanding Bloodborne Pathogens and annual training for Infection Control: Essential Principles.
The facility failed to ensure infection control training was completed for three staff members. The DON stated that annual competencies and required training are tracked through Relias, but review of employee files showed no evidence of infection control training for two GNAs and an LPN, and the DON acknowledged the annual training had not been completed.
Surveyors found that the facility did not provide required annual infection control in-service education to a nurse aide, despite a policy requiring at least 12 hours of annual continuing education for NAs in line with OBRA regulations and completion prior to annual review. Review of the aide’s personnel file showed no documented infection control training for a full annual period, and the Clinical Nurse Educator confirmed that this staff member had not received the mandated infection control training, resulting in noncompliance with state staff development and licensee responsibility requirements.
Failure to Provide Required Infection Control Training
Penalty
Summary
The facility failed to provide Infection Control training for five of five staff members identified in the report: NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8. 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 attendance is to be recorded on each employee’s Record of In-Service. However, review of the personnel files for each of the five employees did not include credible annual in-service training on Infection Control for the period from 1/1/25 through 12/31/25. The personnel records reviewed showed that NA Employee E4 was hired on 3/20/24, NA Employee E5 on 10/22/19, RN Employee E6 on 5/30/19, LPN Employee E7 on 10/19/15, and NA Employee E8 on 3/9/81. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide Infection Control training for these five staff members. The cited regulations were 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.20(a)(d) Staff development.
Missing Infection Control Training for Multiple Staff
Penalty
Summary
The facility failed to provide mandatory training on the infection prevention and control program standards, policies, and procedures for 9 of 17 direct care staff reviewed. Record review showed no evidence of initial hire infection prevention and control training for CNA K, CNA F, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director, and the ADON, and no evidence of annual infection prevention and control training for CNA E. The personnel files reviewed showed hire dates for each of these employees, but the required infection control training documentation was absent. During interviews, the ADON stated he was not aware the infection control and prevention training had not been completed on his hire date before he started resident care and said staff were assigned training through a computer program. The HR staff member said she was new to the position and was not aware the required infection control training had not been completed for all employees. The Administrator stated staff were initially trained by logging into a website and watching training videos, and acknowledged responsibility for ensuring required orientation and annual training were completed. The DON also stated nursing staff were responsible for receiving infection control training during orientation prior to employment and annually. A facility policy revised 02/2026 required all personnel to participate in initial orientation and regularly scheduled in-service training, including infection prevention and control program standards, policies, and procedures.
Failure to Provide Required Infection Control Training
Penalty
Summary
The facility failed to provide required Infection Control training for five staff members, including one LPN, one RN, and three NAs. Review of the facility’s In-Service Training policy showed that all staff were required to participate in regular in-service education on topics including the infection prevention and control program standards, policies, and procedures, with training to be completed before providing care, annually, and as needed based on the facility assessment. The policy also required documentation of the date and time of training, the topic, a summary of the competency assessment, and the hours completed. During interviews, the NHA stated that the facility had recently made staff complete education and later stated that 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 LPN Employee E6, RN Employee E7, NA Employee E8, NA Employee E9, and NA Employee E10 showed education test packets dated in March 2026, but no annual in-service training on Infection Control from 1/1/25 through 12/31/25. The NHA confirmed that the facility failed to provide Infection Control training for these five staff members.
Missing Infection Control Training for Staff Member
Penalty
Summary
The facility failed to provide required infection control training for one of ten staff records reviewed, OSM #3, a speech and language pathologist. On 2/20/26, surveyors requested evidence of infection control training for OSM #3, but a review of records provided by the Director of Human Resources did not show that the training had been completed. During an interview on 2/24/26, the Director of Human Resources stated that new employees receive required trainings through a third-party education provider, that completed trainings are transferred into another third-party software, and that she does not personally verify which trainings are required for each employee or keep up with the specific subject matter trainings required by regulations. Facility documents reviewed included onboarding curriculum listing online required training for Understanding Bloodborne Pathogens and annual training assignments for 2026 listing Infection Control: Essential Principles.
Missing Infection Control Training for Staff
Penalty
Summary
The facility failed to ensure staff received infection control training as part of its infection prevention and control program, which includes mandatory training with written standards, policies, and procedures. During the annual survey, the Director of Nursing reported that nursing skills competencies are verified at orientation and reassessed annually, and that the facility uses Relias for required monthly and annual training. Review of the facility assessment approved in January 2026 identified staff training requirements including infection control. However, review of the employee files for GNA #36, GNA #37, and LPN #38 showed no evidence of infection control training, and the DON later acknowledged that the required annual infection control training for these three staff members was not completed in 2025.
Failure to Provide Required Infection Control Training to a Nurse Aide
Penalty
Summary
The facility failed to provide required infection control training to one of seven nurse aides, resulting in noncompliance with its own infection prevention and control program and staff development policies. The facility’s policy titled “Inservice - Mandatory Hours for Nurse Aides,” dated January 2026, states that nurse aides must receive at least 12 hours of annual continuing education through in-services or seminars, in accordance with OBRA regulations, and that these 12 hours must be completed prior to the aide’s annual review. Review of the personnel file for one nurse aide (Employee E5), hired on 11/4/20, showed no documentation of annual in-service training on infection control for the period from 11/4/24 through 11/4/25. During an interview on 2/25/26 at 1:24 p.m., the Clinical Nurse Educator (Employee E8) confirmed that the facility failed to provide infection control training for this staff member. The deficiency is cited under 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.20(a)(d) Staff development, based on the lack of documented infection control education for the identified nurse aide during the specified annual period.
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