Failure to Provide and Document Required Infection Control Training for Clinical Staff
Summary
The deficiency involves the facility’s failure to ensure that staff received mandatory infection prevention and control education as required by its infection control program and staff development policies. A registered nurse hired in early August 2024 had a personnel file that included a signed job description and a general new employee orientation acknowledgment, but there was no documentation specifying what training topics were covered, and no evidence that infection control training had been completed. Review of the in-service training log and the facility’s electronic training system, confirmed by the HR representative, showed that infection control training was neither assigned nor completed for this nurse at the time of survey. A similar lack of documentation was found for an LPN hired in September 2016. The LPN’s personnel file contained a signed job description requiring participation in all required trainings, but there was no evidence of completed infection control training. The HR representative and surveyor verified in the training system that infection control training had not been assigned or completed for this LPN. After survey exit, the facility submitted an email with an attached “Clinical Staff Annual Education” roster listing both the RN and LPN with handwritten check marks indicating training completion, but the document did not clearly indicate when the training occurred or provide specific dates of completion. Additional staff interviews supported the finding that infection control education was not consistently provided or documented. An LPN reported that staff receive monthly in-services and annual computer-based training and stated that training on infection control is important so staff do not spread infections. A CNA, described as relatively new, reported receiving on-the-job training but no infection control training, and was told there would be online training to complete within two months. The DON stated that staff are expected to complete onboarding orientation and periodic education throughout the year, and emphasized that infection control training is important to prevent knowledge deficits that could delay responses and impact care. Facility policies and the facility assessment specified that infection control education is mandatory on hire and annually, and that infection control is a required competency to be started during orientation and completed within the first weeks of hire and then annually, but the documented practices for the identified staff did not align with these requirements.
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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