Failure to Ensure Staff Training on Resident Rights and Facility Responsibilities
Summary
The facility failed to ensure that staff members were educated on resident rights and facility responsibilities, as required during orientation and annually. Specifically, three employees (an Occupational Therapist, a Certified Nursing Assistant, and a Housekeeper) did not complete the necessary training. The Occupational Therapist and Certified Nursing Assistant did not complete the training during their orientation, and the Housekeeper did not complete the annual training as required. This lapse in training could affect residents by leaving them uninformed due to the lack of staff training. Interviews with the Director of Nursing, the Administrator, and the Human Resources Director revealed that there was an issue with the computer-based training system, which failed to trigger the required training for staff during orientation and annually. The Director of Nursing and the Administrator both indicated that they expected all required trainings to be completed during orientation and annually. The Human Resources Director acknowledged the issue with the training system and its failure to ensure that staff completed the necessary training. The facility's Training Programs policy, dated October 2021, mandates that employees receive appropriate training upon hire and on an ongoing basis to meet state and federal regulations.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Resident Rights Training Documentation: Review of 6 staff records found no documented Resident Rights training, even though other required trainings such as abuse, dementia, infection control, and QAPI were present. The packets later provided were inconsistent and unclear, with one sign-in sheet focused on language in care areas and another packet lacking a defined topic, trainer, or clear documentation of Resident Rights education.
Staff were not educated on resident rights and facility responsibilities related to voting. Residents stated they had not voted, the SSD was unaware of the election and had not arranged transportation, the IAD did not know who was responsible for informing residents or asking if they wanted to vote, and the AADM acknowledged the election was not posted on the activity calendar. Surveyors also found resident rights were not posted throughout the facility as required by policy.
Missing annual resident rights training was identified for a dietary server, a PTA, and a speech therapist. Facility records did not show resident rights training for these employees, and the DON and HRD gave differing accounts about required training for dietary, therapy, and contracted staff. The facility policy stated that all new and existing staff, volunteers, and contractors are to receive training on resident rights and facility responsibilities.
Failure to complete resident rights training for a new Operations Manager was identified during record review and interviews. The employee’s training log showed no evidence of completing the required initial resident rights training within 21 days of hire, despite the facility’s new hire training acknowledgement stating LMS training is due within the first 21 days. HR, the DON, and the Operations Manager stated staff were expected to complete training on time and supervisors were responsible for ensuring completion.
The facility failed to ensure agency CNA P, CNA Q, and LN K had documentation of required resident rights training. Administrative Staff B stated the facility expected the agency to have already provided the required training and in-services before scheduling agency staff, and the facility could not provide a policy related to staff required in-services.
Failure to provide Resident Rights training to five of five direct care staff was identified after the NHA stated that education is tracked by calendar year and that no 2025 education records could be found for the identified LPN, NAs, and RN. The HR Director confirmed the missing training records for all five staff members.
Missing Resident Rights Training Documentation
Penalty
Summary
The facility failed to comply with employee training requirements related to Resident Rights for 6 of 6 staff records reviewed during the annual survey. During record review and staff interviews, the Human Resource Director stated that the employee records for the six staff members were with the Nursing Home Administrator. When the records were provided, they included training for Abuse, Dementia, Infection Control, and QAPI, but no employee training for Resident Rights was documented. The Nursing Home Administrator later provided a Resident Rights packet dated 3/17/2026, but the attached in-service sign-in sheet was titled "Be mindful of the conversations and language used in patient care areas and hallways," rather than Resident Rights. A second Resident Rights packet was then provided, but it lacked a defined topic; one page was dated 11/3/2025 and the other was undated, and neither page identified the trainer or the topic. A review of the facility assessment showed that Resident Rights and facility responsibilities were listed as a primary education requirement, but no additional documentation of Resident Rights training was provided by the time of exit.
Failure to Educate Staff on Resident Rights and Voting Access
Penalty
Summary
The facility failed to ensure staff members were educated on residents' rights and the facility's responsibilities to support residents in exercising those rights, including the ability and option to vote. During the Resident Council meeting, residents in attendance stated they had not voted the previous day. The Social Services Designee stated none of the residents came to ask for transportation to vote and that she was not following the election or aware of the California Primary election. The Interim Activities Director stated she did not know who was responsible for informing residents about an upcoming election, acknowledged residents had not received election information from the Activities Department, stated residents were not asked if they wanted to vote, and stated no vote-by-mail ballots were received for residents. The Assistant Administrator stated past elections were posted on the activity calendar, but acknowledged the California election was not posted on the June 2026 activity calendar and was not aware whether activity staff asked residents if they wanted to participate. A review of the activity calendar showed the June 2, 2026 California primary election was not listed as an offered activity. Observation of the facility found no posted copies of resident rights throughout the building as required by the facility's policy. The Assistant Administrator stated resident rights copies may be in a binder and acknowledged she had not read the policy requirements and that resident rights were not posted throughout the facility.
Missing Annual Resident Rights Training for Multiple Staff
Penalty
Summary
The facility failed to ensure that three staff members received annual training on resident rights. Review of the staffing list and transcript histories showed that the dietary server, the physical therapy assistant, and the speech therapist did not have resident rights training listed in their records. For the dietary server and the physical therapy assistant, the facility could not verify when the annual resident rights training had been completed. For the speech therapist, the transcript also did not list resident rights training, and the transcript showed other modules were started on several later dates. During an interview, the DON stated that the facility uses an eCampus for annual module training and weekly meetings for additional topics, including resident rights, abuse and neglect, infection control, emergency preparedness, and dementia care. She stated that the therapy team and dietary staff take the same training as nursing staff and that she expects staff to complete required training modules. The HRD stated that the dietary server had a different learning plan and was not required to have abuse and infection control training, and also stated that the contracted rehabilitation company should provide its employees the same training as the facility provides to its employees. The facility policy titled Staff Development and Orientation-Resident Care, revised 10/2023, stated that all new and existing staff, volunteers, and contractors will receive training on resident rights and facility responsibilities, abuse, neglect and exploitation, dementia management, and infection control. The speech therapist stated that she had received orientation training that should have included abuse, infection control, Elder Justice Act, emergency preparedness, and resident rights, and that there should be a transcript documenting it; however, the transcript reviewed did not list those trainings.
Failure to Complete Resident Rights Training for New Operations Manager
Penalty
Summary
The facility failed to provide resident rights training for 1 of 28 employees reviewed for training, specifically the Operations Manager. Record review showed the Operations Manager was hired on 04/24/2026, and the training log from human resources showed no evidence that the initial resident rights training was completed within 21 days of hire, as required by the facility's training policy. A facility new employee training acknowledgement stated that New Hire LMS Training is due within the first 21 days of the start date. During interview, HR O stated newly hired employees were expected to complete new hire training within 21 days of hire and that employees signed an agreement at orientation stating they would complete training timely. In a group interview, HR P, the DON, and the Operations Manager stated employees were responsible for completing training within 21 days, and supervisors were responsible for ensuring staff completed training within 21 days and annually. HR P and the Operations Manager stated they were new in their positions and were unaware that staff had not completed training or how it could affect residents. The requested policy addressing annual employee training was not provided prior to exit.
Failure to Verify Agency Staff Resident Rights Training
Penalty
Summary
The facility failed to ensure agency staff received the required resident rights training. During record review on 05/14/26, documentation could not be provided showing that agency CNA P, CNA Q, and LN K had completed resident rights training. During an interview later that day, Administrative Staff B stated she was responsible for scheduling agency staff and that the facility expected the agency to have already provided the required training and in-services to its staff before they were scheduled at the facility. The facility was also unable to provide a policy related to staff required in-services when requested.
Failure to Provide Resident Rights Training to Direct Care Staff
Penalty
Summary
The facility failed to provide Resident Rights training to five of five direct care facility staff reviewed, including an LPN, three NAs, and an RN. During interviews, the NHA stated that staff education is tracked by calendar year from January through December and that State Agency requested employee education records for the identified staff. The NHA later stated that the facility was unable to find any education records for those employees for the year 2025. The HR Director also confirmed that the facility failed to provide Resident Rights training to five of five direct care facility staff.
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