Deficient Training and Communication for Agency Staff on Resident Care Requirements
Summary
The facility failed to establish an effective training and communication system for contracted agency staff regarding the level of care required by residents. Agency CNAs were expected to review resident care information in a binder and use care cards located in residents' closets to determine transfer needs. However, documentation showed that not all agency CNAs had signed off on having reviewed this information. Interviews with agency CNAs revealed that some did not recall signing any forms or receiving adequate training upon starting at the facility, and one CNA stated that it was difficult to know how to care for residents due to insufficient information provided by the facility. Further interviews with facility staff, including an LPN and the DON, confirmed that staff were expected to follow care cards for resident transfers, but this was not consistently done. The DON acknowledged that staff did not always adhere to the care cards, as evidenced by some resident falls. The Administrator also recognized that the current system for educating agency staff was ineffective, noting that more agency staff were present than had signed the education sheet and that some agency staff were unaware of the care cards.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not ensure that CNAs received the required minimum of 12 hours of annual in‑service training. A review of three CNAs’ education records showed that one CNA had completed only 10.47 hours of training for the current annual period. The DON confirmed that this CNA had been skipping course content and going directly to the test, resulting in incomplete training hours. This deficiency had the potential to affect all residents receiving care from CNAs, as inadequate training places residents at risk for harm due to staff not being fully prepared to safely provide required services.
The facility did not ensure that all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention. Review of records for two agency CNAs showed no documented annual CNA training, despite a facility assessment stating that nurse aide in‑services must total at least 12 hours per year and address competency needs. One agency CNA reported not receiving any annual competency training or knowing it was required, and another reported receiving no training in the past year while providing care to all residents. The AIT and DON confirmed that these CNAs had not received the required annual training from either the facility or their agency.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
The facility did not ensure that CNAs received the required minimum of 12 hours of annual in-service education, including dementia care and abuse prevention. Surveyors found, through staff interviews and record review, that two CNAs hired more than a year earlier had not completed at least 12 hours of in-service training during their most recent anniversary year. The NHA confirmed that these CNAs had not met the annual training requirement and acknowledged that CNAs are expected to receive at least 12 hours of in-service education each year.
The facility failed to provide required in-service training on dementia management and resident abuse prevention for five sampled staff members, including an RN, an LPN, and three NAs. It also failed to document that three sampled NAs received the required 12 hours of annual in-service education. The NHA confirmed the missing training and documentation during interview.
The facility did not ensure that two nurse aides completed the required 12 hours of annual in‑service education, including dementia management, abuse prevention, and training to address performance weaknesses. One aide had only a brief in‑service on infection control and respirator use, while another had less than four hours of training focused on safe resident handling, mechanical lift use, elopement prevention, and ethics. The DON and the NHA confirmed that the required annual in‑service training had not been completed, resulting in noncompliance with state personnel and staff development regulations.
Failure to Ensure Required Annual CNA In‑Service Training Hours
Penalty
Summary
The facility failed to ensure that CNAs received the required minimum of 12 hours of annual in‑service training, including dementia care and abuse prevention, as evidenced by a review of training records and staff interviews. On 04/29/26, surveyors requested annual education records for three CNAs and found that one CNA had completed only 10.47 hours of training for the current annual period, which did not meet the 12‑hour requirement. During an interview, the DON confirmed that this CNA did not have the required annual CNA training hours and explained that the CNA had been skipping the course content and proceeding directly to the test, resulting in incomplete training hours. This deficient practice was identified as having the potential to affect all residents receiving care from CNAs, as inadequate training places residents at risk for harm due to staff not being fully prepared to safely provide required services.
Failure to Provide Required Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure all CNAs received the required 12 hours of annual competency in‑service training, including dementia care and abuse prevention, as required by its Facility Assessment Tool and federal regulations. The Facility Daily Census Report documented 72 residents residing in the facility at the time of the survey. The Facility Assessment Tool specified that required in‑service training for nurse aides must be at least 12 hours per year, sufficient to ensure continuing competence, address areas of weakness identified in performance reviews and the facility assessment, and may address special resident needs. Review of employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of the required 12 hours of annual CNA competency training. During interviews, one agency CNA (V9) stated that they had not received 12 hours of annual competency training from either the facility or the hiring agency and were unaware of the requirement for 12 hours of annual training. Another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) both confirmed that V9 and V10 had not received the required 12 hours of annual CNA training from either the facility or the agency that employed them.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) received the required minimum of 12 hours of in-service training during their most recent anniversary hire year, including education in dementia care and abuse prevention. Record review on 4/13/26 showed that CNA-Z, hired on 6/14/21, had not completed at least 12 hours of educational training during the most recent anniversary year. On the same date, review of records for CNA-AA, hired on 10/23/23, also showed that this CNA had not completed the required 12 hours of in-service education during the most recent anniversary hire year. In an interview on 4/13/26 at 3:45 PM, the Nursing Home Administrator confirmed that both CNAs had not met the 12-hour annual in-service education requirement and acknowledged that CNAs are expected to receive at least 12 hours of in-service education per year. No resident-specific medical histories or conditions were described in the report, and the deficiency centers on the facility’s failure to provide and document the mandated annual in-service training hours for the identified CNAs.
Missing Dementia and Abuse Prevention Training
Penalty
Summary
The facility failed to provide training on Dementia Management and Resident Abuse Prevention for five of five sampled staff members, including three nurse aides, one RN, and one LPN. 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 annual in-services are to be no less than 12 hours per employment year. However, review of the personnel files for NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8 did not include credible annual in-service training on Dementia Management and Resident Abuse Prevention for the period reviewed. The facility also failed to ensure that three of three sampled nurse aides received a minimum of 12 hours of in-service education per year. Review of the nurse aide training records for NA Employee E4, NA Employee E5, and NA Employee E8 did not include credible documentation showing they received 12 hours of in-service training during the reviewed year. During interview, the Nursing Home Administrator confirmed that the facility failed to provide the required training on Dementia Management and Resident Abuse Prevention for the five staff members and failed to ensure the three sampled nurse aides received the required annual in-service hours.
Failure to Provide Required Annual In‑Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that two nurse aides received the required 12 hours of annual in‑service training, including dementia management, resident abuse prevention, and training to address identified performance weaknesses. Review of personnel records showed that NA 1 was hired on August 28, 2023, and facility training records for the period April 17, 2025, to April 17, 2026, documented only 31 minutes of in‑service education for NA 1, limited to infection control and respirator use. Review of NA 2’s personnel record showed they were hired on December 19, 2023, and training records for the same period documented only 3 hours and 48 minutes of in‑service education for NA 2, covering safe resident handling, mechanical lift use, elopement prevention, and ethics. In an interview on April 17, 2026, at 12:59 p.m., the DON and the Nursing Home Administrator confirmed that NA 1 and NA 2 had not completed the required annual in‑service training. These findings were cited under 28 Pa. Code 201.19(7) related to personnel policies and procedures and 28 Pa. Code 201.20(a)(6)(d) related to staff development.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.