Failure to Provide Fire Safety Training
Summary
The facility failed to provide mandatory training on Fire Prevention and Safety for one of its staff members, identified as Employee E12. According to the facility's "Facility Assessment" dated January 26, 2025, new staff are required to receive training during orientation, and existing staff are to be trained monthly on specific topics to meet educational requirements. However, a review of the facility's documents and training records revealed that Employee E12, who was hired on July 1, 2023, did not receive documented in-service education on Fire Prevention and Safety between July 1, 2023, and July 1, 2024. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 14, 2025.
Plan Of Correction
Nurse aide employees will be trained on fire prevention and safety by 4.14.2025. To prevent this from recurring, the NHA/designee educated Human Resources on regulatory requirements of F1580. To monitor and maintain ongoing compliance, the DON/designee will audit employee training records for fire prevention and safety weekly x4, then monthly x2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Penalty
The facility did not provide annual Fire Prevention and Safety training to several staff members, including multiple nurse aides and an LPN, as required by facility policy. Personnel files lacked documentation of this training for the relevant annual periods, and this was confirmed by Human Resources.
The facility failed to provide required fire safety training to three nurse aides, as mandated by regulations. A review of training records revealed that these staff members did not receive documented fire safety education within the specified timeframe. The Nursing Home Administrator confirmed this deficiency during an interview.
Failure to Provide Annual Fire Prevention and Safety Training to Staff
Penalty
Summary
The facility failed to provide required training on Fire Prevention and Safety to six out of seven reviewed staff members, including five nurse aides and one LPN. According to the facility's own 'Training Requirements' policy, all staff, contractors, and volunteers must receive training in key areas, including fire prevention and safety, prior to independently providing services, annually, and as needed based on the facility assessment. Personnel file reviews for the identified staff members showed no documentation of Fire Prevention and Safety training within the required annual period. During an interview, the Human Resources employee confirmed that the required training had not been provided to these staff members. The deficiency was identified through a review of personnel files and facility policy, with specific hire dates and missing training periods noted for each affected staff member. No information about residents or their conditions was included in the report.
Plan Of Correction
Employees 4, 5, 6, 7, 8, and 9 will receive the Fire Prevention training in January 2026. All employees will receive an annual Fire Prevention training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Fire Prevention training. Human resource Director or designee will audit the training to assure all staff have been educated on Fire Prevention training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Provide Fire Safety Training to Nurse Aides
Penalty
Summary
The facility failed to provide mandatory fire safety training to three out of five nurse aides, as required by 42 CFR 483.90. The deficiency was identified through a review of the facility's policy on in-service training, personnel training records, and staff interviews. Specifically, Nurse Aide Employee E11, hired on 3/26/23, did not receive fire safety training between 3/26/24 and 3/26/25. Similarly, Nurse Aide Employee E13, hired on 3/14/05, and Nurse Aide Employee E15, hired on 4/14/14, also lacked documented fire safety training for the period between 3/14/24 and 3/14/25, and 4/14/24 and 4/14/25, respectively. The Nursing Home Administrator confirmed the absence of this essential training during an interview conducted on 4/18/25.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Fire Prevention and Safety on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 1580 was not uploaded to the training platform. Fire Prevention and Safety has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 1580 training courses completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
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