Deficiency in Staff Education on Resident Rights
Summary
The facility failed to ensure that staff members received mandatory education on resident rights and facility responsibilities, as evidenced by a review of employee education files. Out of six employees reviewed, five did not have records of completing this essential training. The staff members identified included two Licensed Practical Nurses (LPNs), two Certified Nursing Assistants (CNAs), and a Dietary Aide. This deficiency was discovered during a review conducted on June 20, 2024, which revealed the absence of documentation supporting the completion of required education in the personnel files of these staff members. The Director of Clinical Service acknowledged the expectation that all staff should complete their core competency requirements, including 12 hours of yearly education and yearly competency evaluations. The facility's policy on Orientation, revised in October 2022, mandates that a general orientation plan be created for all newly hired employees, which must be completed before any formal contact with residents. This policy also requires the use of checklists to document training and competency evaluations, with all documentation maintained in the employee's personnel file. Despite these policies, the facility did not provide the necessary documentation upon request, indicating a lapse in adherence to their own training and documentation procedures.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
The facility did not provide evidence that 5 of 5 reviewed CNAs received required resident rights training. The CNAs had been employed for more than 1 year, but the facility could not produce training records. HR stated onboarding was handled by HR, annual training was not tracked there, and there was no Nurse Educator or Staff Development Coordinator. The NHA and DOP confirmed there was no organized system for employee training records.
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.
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.
Missing Resident Rights Training for Direct Care Staff
Penalty
Summary
The facility did not ensure that direct care staff received the required resident rights training. Based on interview and record review, 5 of 5 Certified Nursing Assistants reviewed—TT, UU, VV, WW, and XX—had worked at the facility for more than 1 year and the facility was unable to provide evidence that they had received resident rights training. The facility policy titled, Training Requirements, states that training content includes resident rights and facility responsibilities for caring for residents, and that documentation of required training is to be forwarded to HR for placement in the personnel file. On 5/4/26, the surveyor reviewed the records of the five CNAs selected from a list of employees provided by the facility. The CNAs had hire dates of 12/4/2024, 10/30/2024, 12/4/2024, 5/7/2024, and 10/30/2024, respectively, and the facility could not provide evidence of the required resident rights training for any of them. During interviews on 5/5/26, the HR Director stated that HR handled new-employee onboarding but did not track annual trainings after hire, and said there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed the facility had no evidence that resident rights training had been provided and stated that training records were in boxes kept by the previous DON, with no organized system for employee trainings.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.