Failure to Maintain Effective Staff Training on Behavioral Health and Communication
Summary
Facility staff failed to develop, implement, and maintain an effective training program for all staff, specifically lacking required education on behavioral health care and communication. During an extended survey conducted after substandard quality of care was identified, surveyors interviewed the Staff Development Coordinator, who stated she had no evidence that behavioral health training had been provided to all staff and acknowledged that some staff only received computer-based training. Review of educational records for five nursing staff members (two RNs, one LPN, and two CNAs) showed no documentation of training on behavioral health care. Staff interviews further revealed that these employees had not received training on communication with a Spanish-speaking resident. Staff reported that they relied on the resident’s family to translate and on the Assistant DON, who spoke Spanish, rather than on any formal training or structured communication process. The Staff Development Coordinator confirmed there was no documentation of any employees receiving training on communication with a Spanish-speaking resident, and surveyors observed that there were no communication tools in the Spanish-speaking resident’s room and no developed or implemented process for communicating with that resident. Facility leadership, including the Administrator, Assistant Administrator, Regional Nurse Consultant, and DON, were informed that required training, including communication training, was not being effectively maintained or documented.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Effective Communication Training: The facility did not have credible annual in-service training on Effective Communication for five reviewed staff members, including NAs, an RN, and an LPN. Personnel file reviews showed the required training was missing for each employee, and the NHA confirmed the lapse during interview.
The facility failed to ensure effective communication training was completed for 6 of 17 direct care staff, including CNAs, LVNs, and the ADON. Record review showed each had a hire date documented, but no evidence of initial effective communication training in their personnel files. During interviews, the ADON, HR, Administrator, and DON stated they were responsible for ensuring required orientation training was completed before staff began resident care and annually, and the facility policy listed effective communication with residents and family as a required topic.
Missing Mandatory Communication Training for Staff: The facility failed to ensure required effective communication training was completed for an LPN and a nursing assistant. The facility assessment stated all staff were to receive communication training, but the administrator verified the training was not completed and the education was not found in the personnel files provided.
The facility failed to provide required Effective Communication in-service training for an LPN, an RN, and three NAs. Facility policy required regular in-service education for direct care staff, but personnel file review showed no annual training documentation for the five staff members, and the NHA stated there was no employee education for the prior year and that the previous HR process had not been done correctly.
Facility staff failed to ensure that a CNA completed required communication training, as revealed through staff interviews and document review. The facility’s assessment identified effective communication as an annual education topic for all staff, and policy required regular in-service education on effective communication with residents and families for direct care staff. However, there was no documentation that the CNA had completed this training, and the staff development coordinator acknowledged that, although an annual competency calendar existed and an effort to catch up on missed education was in progress, the communication training for this CNA was not completed or documented at the time of review.
The facility failed to provide required communication training for three CNAs whose employee records were reviewed. Record review showed the training was missing, and the DON verified the deficiency during the survey. The policy for the required training elements was requested but not provided prior to exit.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide training on Effective Communication for five of five staff members reviewed: Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8. Review of the facility’s In-Service Training Program policy for nurse aides indicated that all nurse aide personnel are to participate in regularly scheduled in-service training classes and that training attendance is to be entered on each employee’s Record of In-Service by the department supervisor or other designated person. Review of the personnel files showed that NA Employee E4, hired 3/20/24, did not have credible annual in-service training on Effective Communication from 1/1/25 through 12/31/25. Similar reviews of the files for NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8 also did not include credible annual in-service training on Effective Communication for that same period. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide training on Effective Communication for these five staff members.
Missing Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide effective communication mandatory training for 6 of 17 direct care staff reviewed for training requirements, including CNA K, CNA F, LVN A, LVN L, LVN M, and the ADON. Record review showed that CNA K, CNA F, LVN A, LVN L, LVN M, and the ADON each had a documented hire date, but there was no evidence in their personnel files that initial hire training on effective communication had been completed. During interviews, the ADON stated he was not aware the effective communication training had not been completed before he started resident care and explained that training was assigned through a computer program by HR or corporate. HR stated she was new to the position and was not aware that effective communication training had not been completed as required for all employees, and said she would complete a checklist for required training going forward. The Administrator and DON both stated they were responsible for ensuring staff received required orientation training on effective communication prior to employment and annually. The facility policy revised 02/2026 stated that all personnel must participate in initial orientation and regularly scheduled in-service training, and that required training topics include effective communication with residents and family for direct care staff.
Missing Mandatory Communication Training for Staff
Penalty
Summary
The facility failed to ensure that mandatory effective communication training was completed for 2 of 10 staff reviewed, including a nursing assistant and an LPN. The facility assessment dated [DATE] stated that the facility had developed a training program with an orientation process and ongoing training for all new and existing staff, and that all staff were to receive training in communicating effectively. During an interview on 4/13/26, the administrator stated she was responsible for overseeing and ensuring all staff completed the required training. On 4/14/26, during a follow-up interview, the administrator was informed that the education on effective communication was not found in the personnel files provided for the LPN and the nursing assistant, and she verified that the trainings had not been completed for either staff member. A facility policy regarding required staff training was requested but not received.
Missing Required Effective Communication Training
Penalty
Summary
The facility failed to provide training on Effective Communication for five of five staff members, including one LPN, one RN, and three NAs. Facility policy titled In-Service Training, All Staff required regular in-service education for direct care staff on effective communication with residents and family, along with other required topics, and stated that training must be completed prior to providing care, annually, and as necessary based on the facility assessment. Completed training was to be documented by the staff development coordinator or designee with the date and time, topic, competency summary, and 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. The NHA explained that the previous HR employee did not do the job correctly and that the outgoing corporate company was not monitoring the work. Review of the personnel files for the five staff members showed no annual in-service training on Effective Communication for 1/1/25 through 12/31/25. The facility did provide education test packets for four staff members, and for one NA the packets were signed but undated.
Failure to Ensure Required Communication Training for Direct Care Staff
Penalty
Summary
Facility staff failed to ensure completion and documentation of required communication training for a certified nursing assistant (CNA #9), constituting a deficiency in the facility’s staff education program. CNA #9 was hired on 7/6/2022, and during staff interview and document review on 4/9/2026, the facility was unable to provide any evidence that this CNA had completed the required communication training, despite the facility assessment listing “Communicating Effectively” as an annual education topic for all staff and the in-service training policy requiring all staff to participate in regular in-service education, including effective communication with residents and families for direct care staff. The staff development coordinator, who began working at the facility in December 2025, reported that there was an annual competency calendar assigning education throughout the year with a completion deadline of December 31, and acknowledged that an ongoing performance improvement plan to catch up on missed education was not yet completed, leaving CNA #9 without documented communication training at the time of the survey. On the date of the survey, leadership including the administrator, DON, vice president of operations, regional director of clinical services, assistant DON, and clinical consultant were informed of the concern, and no additional information or documentation demonstrating completion of communication training for CNA #9 was provided prior to survey exit.
Failure to Provide Required Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide required communication training for three of ten employee records reviewed, including CNA #1, CNA #2, and CNA #3. During record review on 5/13/2026 at 6:00 p.m., the employee training records for these three CNAs were requested and reviewed, and none contained the required training in communication. On 5/14/2026 at approximately 3:45 p.m., the DON verified that the three CNAs did not have the required communication training. A request was made for the policy outlining the required training elements, but it was not provided prior to exit. The Executive Director, DON, and Regional Director of Operations were informed of the finding on 5/14/206 at 4:10 p.m.
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