Failure to Verify Agency Staff Competency and Provide Fall Prevention Training
Summary
The deficiency involves the facility’s failure to ensure that a resident received care from staff with documented competency and training, particularly in fall prevention and resident-specific safety needs. An agency CNA was assigned to provide ADL care to an alert and oriented, predominantly Polish‑speaking resident with multiple diagnoses including type II diabetes, right humerus fracture history, COPD, atrial fibrillation, hypertension, anxiety disorder, and a history of falls. During incontinence care, the CNA positioned the resident on her side with one hand on the resident’s rib/shoulder area and the other hand cleaning a large bowel movement. The resident then reached toward the bedside table or an item on it, rolled out of the bed, and fell to the floor. The CNA reported there were no bed rails, that she did not understand the resident due to the language barrier, that it was her first time caring for the resident, and that no one had given her any information about the resident’s care needs or fall risk status. Following the fall, the resident complained of right shoulder pain and had a laceration above the right eye, was sent to the ED, and returned with a diagnosed right humerus fracture and a laceration treated with Steri‑strips. Record review showed that the facility’s orientation documentation for the agency CNA consisted of a form listing over two dozen training topics, including fall prevention and safety protocols, all marked only with a single continuous vertical strike‑through line and the CNA’s signature, without instructor initials, dates of completion, or evidence of observed competency by facility leadership. The CNA stated she did not recall receiving fall prevention training. An agency LPN caring for the same resident reported receiving no in‑service training from the facility, only from the agency, and incorrectly stated that the resident was not a fall risk despite being aware of a prior fall. When the surveyor requested a fall prevention policy, the administrator provided only a Fall Occurrence policy that addressed assessment and interventions after falls and confirmed there was no separate fall prevention policy. Review of the facility’s education modules showed staff were trained only on the fall occurrence policy, not on a proactive fall prevention framework. As a result, the agency CNA was assigned to a high‑risk resident without verified competency in the facility’s safety standards or resident‑specific fall prevention needs.
Penalty
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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.
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