Deficiency in Mandatory Training on Resident Rights
Summary
The facility failed to ensure that training on resident rights was included as mandatory training for direct care staff. This deficiency was identified through interviews and a review of staff education records for five direct care staff members, including two nurses and three certified nursing assistants (CNAs). The facility's policy, revised on 3/4/24, mandates that training on resident rights and facility responsibilities should be completed prior to staff independently providing services to residents, annually, and as necessary. However, the facility was unable to provide the surveyor with education records for two nurses, and the records for the three CNAs did not include the mandatory training on resident rights. During interviews, the Staff Development Coordinator (SDC) acknowledged that all education files and records had been provided to the survey team and confirmed that the facility did not use electronic training programs. The SDC, who had been in the role for three months, admitted to trying to catch up on mandatory trainings and confirmed the absence of evidence for training on resident rights. The Chief Nursing Officer (CNO) stated that the mandatory training should be completed upon hire and annually. Despite the SDC's efforts to locate additional records, no further documentation was provided to the survey team by the end of the survey.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Resident Rights Training: The facility did not have credible annual in-service training documentation on Resident Rights for five staff members, including NAs, an RN, and an LPN. Personnel file review showed the required training was missing for each employee, and the NHA confirmed the lapse during interview.
Failure to Complete Required Resident Rights Training: The facility failed to ensure CNA E completed required education on resident rights and facility responsibilities. Record review showed CNA E had no evidence of annual training since hire, and training was only initiated after surveyor entrance but not completed. The HR Coordinator, Administrator, and DON each stated the training was required on hire and annually, and facility policy listed resident rights and responsibilities as a required topic.
Failure to Provide Resident Rights Training: The facility did not provide required Resident Rights in-service education for an LPN, an RN, and three NAs. Personnel files lacked annual training documentation, and some education packets were undated or incomplete. The NHA stated the facility could not locate 2025 education records and later confirmed there was no employee education for that year.
A CNA’s training record did not show the required resident rights education. During record review, the DON verified the missing training, and the policy for required training elements was not provided prior to exit.
A facility failed to provide evidence that an SLP completed required training on resident rights and facility responsibilities. Surveyors requested the record, but HR could not show completion. HR stated that new hires get training lists from a third-party provider, completion is online, and she does not personally verify which regulatory trainings each employee must complete. The onboarding curriculum reviewed included resident rights for all community team members.
The facility failed to provide required Resident Rights training to an LPN and a NA, as identified through review of policies, in-service records, and personnel files. Facility policies require annual continuing education for nurses and at least 12 hours of annual education for NAs, including topics such as Resident Rights. However, the LPN’s file lacked documentation of Resident Rights in-service training for a full anniversary year, and the NA’s file similarly lacked this training for a subsequent annual period. The Clinical Nurse Educator confirmed that these two of seven staff reviewed had not received the mandated Resident Rights education.
Failure to Provide Resident Rights Training
Penalty
Summary
Staff members were not provided training on Resident Rights as required by facility policy and staff development requirements. 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 training attendance is to be recorded on each employee’s Record of In-Service. However, review of 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 Resident Rights for the period 1/1/25 through 12/31/25. The five employees identified had hire dates ranging from 3/20/24 to 3/9/81, and none of their personnel files contained the required Resident Rights in-service documentation for the annual period reviewed. 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 Resident Rights for these five staff members.
Failure to Complete Required Resident Rights Training
Penalty
Summary
The facility failed to provide required education on resident rights and the responsibilities of a facility to properly care for its residents for 1 of 17 employees reviewed, CNA E. Record review of CNA E’s personnel file showed a hire date of 06/29/2024, and there was no evidence of annual training since the hire date on resident rights and facility responsibilities. Electronic training records showed CNA E initiated training on 04/15/2026, after surveyor entrance on 04/13/2026, but the training was not completed. During interviews, the HR Coordinator stated she was responsible for ensuring resident rights training was completed annually and upon hire, and said mandatory training should be completed on hire and annually so employees are knowledgeable. She acknowledged CNA E’s training was not completed annually as required by policy. The Administrator stated all mandatory training was required at the time of hire before staff started employment and annually thereafter, and said the risk of not completing resident rights training could cause the employee to not know what the rights were and could lead to violations. The DON stated she was responsible for monitoring incomplete training modules for nursing staff and said one reason for staff failing to complete training was a breakdown in communication. Facility policy revised 02/2026 stated all personnel must participate in initial orientation and regularly scheduled in-service training, and listed resident rights and responsibilities as a required training topic.
Failure to Provide Resident Rights Training
Penalty
Summary
Staff members were not provided training on Resident Rights and facility responsibilities as required by facility policy. Review of the facility's In-Service Training policy showed that all staff are required to participate in regular in-service education on topics including resident rights and responsibilities, abuse prevention, QAPI, infection prevention and control, behavioral health, and compliance and ethics, with training 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, topic, competency assessment summary, and hours completed. Review of personnel files showed no annual in-service training on Resident Rights for five staff members: an LPN, an RN, and three NAs. The facility provided education test packets for some of the staff, but the records did not show annual Resident Rights training for 1/1/25 through 12/31/25, and one NA's packets had no date present. During interviews, the NHA stated the facility had recently made staff complete education, could not locate employee education records for 2025, and later confirmed there was no employee education for 2025 because the previous HR employee had not done the job correctly and the outgoing corporate company had not monitored the work.
Missing Required Resident Rights Training for CNA
Penalty
Summary
Staff members were not educated on resident rights and facility responsibilities as required, based on staff interview, facility document review, and employee record review. During review of employee training records for CNA #3, the required training in resident rights was not present. On 5/14/2026 at approximately 3:45 p.m., the DON verified that CNA #3 did not have the required resident rights training. A request for the policy outlining the required training elements was made but was not provided prior to exit, and the Executive Director, DON, and Regional Director of Operations were informed of the finding on 5/14/2026 at 4:10 p.m.
Missing Required Resident Rights Training
Penalty
Summary
The facility failed to provide required training in resident rights and facility responsibilities for one of ten staff records reviewed, OSM #3, a speech and language pathologist. On 2/20/26, surveyors requested evidence of this training, but the facility records provided by the Director of Human Resources did not show that the training had been completed. On 2/24/26, the Director of Human Resources stated that new employees receive a list of required trainings through a third-party education provider at hire, that the trainings are completed online, and that completion records are transferred to another third-party software. She also stated that she does not personally verify which trainings are required for each employee and does not keep up with the specific subject matter trainings required by regulations. A review of the facility’s onboarding curriculum for all staff showed resident rights as part of the required training.
Failure to Provide Required Resident Rights Training to Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide required training on Resident Rights to specific staff members. Facility policies titled "Inservice - Mandatory Hours for Registered Nurses (RN) and Licensed Practical Nurses" and "Inservice - Mandatory Hours for Nurse Aides," both dated January 2026, state that RNs and LPNs will be given opportunities for annual continuing education through in-services, self-studies, or seminars, and that each nurse is responsible for attending in-services each anniversary year. The policies also state that nurse aides must complete at least 12 hours of annual continuing education, as required by OBRA regulations, and that the facility has an obligation to provide continued training and education so team members can perform their jobs effectively. Review of personnel files showed that an LPN hired on 3/31/21 did not have documentation of annual in-service training on Resident Rights for the period 3/31/24 through 3/31/25. Similarly, a nurse aide hired on 11/4/20 did not have documentation of annual in-service training on Resident Rights for the period 11/4/24 through 11/4/25. Based on review of facility policy, in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Resident Rights for two of seven staff members reviewed. During an interview, the Clinical Nurse Educator confirmed that these two staff members had not received the required Resident Rights training.
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