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 did not provide required Resident Rights education to multiple direct care staff members. Review of the continuing education policy showed that all employees were expected to complete mandatory trainings within set time frames, and HR reported that education is organized by calendar year. However, review of 2025 training records revealed that a NA, two RNs, and another NA lacked documented Resident Rights training. The NHA confirmed that Resident Rights training had not been provided to these direct care staff, resulting in noncompliance with state staff development and license responsibility requirements.
A dietary aide was found to have not received the required Resident's Rights training, as confirmed by a review of employee records and interviews with the DON and Regional Director of Clinical Services. Documentation provided was either dated prior to the aide's hire or did not show evidence of the necessary training, and no facility policy or additional proof was presented.
Six staff members, including multiple nurse aides and an LPN, did not receive required annual training on Resident Rights as mandated by facility policy. Personnel file reviews and staff interviews confirmed the absence of this training within the specified period.
Two direct care staff members, a nurse aide and an LPN, did not complete required annual education on resident rights, as confirmed by personnel file reviews and facility leadership. This failure occurred despite job descriptions and facility policy mandating such training.
A nurse aide did not receive required training on Resident Rights, as confirmed by a review of education records and staff interview. The Nursing Educator acknowledged that this staff member was not provided the mandated education.
The facility did not ensure that staff completed required Resident Rights education. Review of personnel files and in-service logs for an RN and an LPN showed no documented completion of Resident Rights training despite signed job descriptions requiring participation in mandatory education and a policy and facility assessment identifying Resident Rights as a required competency. HR acknowledged that Resident Rights training had not been assigned or was assigned but not completed, and that the training system was not consistently loading required courses. An LPN and a CNA reported that while in-services and computer-based training occur, Resident Rights training was not consistently provided, and the DON stated that Resident Rights education is expected during orientation and periodically thereafter to prevent knowledge deficits that could delay responses and impact care.
Failure to Provide Resident Rights Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Resident Rights training to most of the direct care staff reviewed, contrary to its own continuing education policy and state regulations. The facility’s Continuing Education policy dated 9/22/25 stated that all levels of employees are expected to complete required trainings within designated time frames, and the Human Resources Director reported that education is conducted on a calendar-year basis from January through December. However, review of 2025 facility education documents showed that a nurse aide (Employee E1), a registered nurse (Employee E3), another nurse aide (Employee E4), and another registered nurse (Employee E6) had no documented training on Resident Rights. During a subsequent interview, the Nursing Home Administrator confirmed that the facility had failed to provide Resident Rights training to these direct care staff members, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.20(c). No specific residents, medical histories, or clinical conditions were described in the report in connection with this deficiency.
Failure to Provide Required Resident's Rights Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required Resident's Rights training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but no credible evidence was found in the employee records to confirm completion of Resident's Rights training. The Director of Nursing (DON) stated that training on resident rights, abuse, and similar topics was expected for all staff, including dietary staff, prior to beginning their duties. However, the only documentation provided was a Skills Competency Validation Record dated before the employee's hire date, and a transcript from the employee's phone app that did not show completion of Resident's Rights training. During interviews, the DON and Regional Director of Clinical Services confirmed that all employees were expected to complete Resident's Rights training, but were unable to provide a facility policy on staff training or any additional documentation to support that the dietary aide had received the required training. No further information was provided by facility staff when given the opportunity to do so.
Failure to Provide Annual Resident Rights Training to Staff
Penalty
Summary
The facility failed to provide required training on Resident Rights to six out of seven reviewed staff members, including five nurse aides and one LPN. According to the facility's own policy, all staff, contractors, and volunteers must receive training on Resident Rights prior to independently providing services, annually, and as necessary based on the facility assessment. Personnel file reviews for these staff members showed no documentation of Resident Rights training within the required annual period. During an interview, the Human Resources employee confirmed that the identified staff members did not receive the mandated Resident Rights training. This deficiency was identified through review of facility policy, personnel files, and staff interviews, and it was determined that the facility did not meet the regulatory requirement to ensure staff are educated on resident rights and facility responsibilities.
Plan Of Correction
Employee's 4, 5, 6, 7, 8 and 9 will receive the resident rights training in January 2026. All employees will receive an annual resident rights training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for resident rights training. Human resource Director or designee will audit the training to assure all staff have been educated on resident rights training topic. Audit results will be turned into the Quality Assurance meeting monthly.
Failure to Provide Resident Rights Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Resident Rights training to two of five direct care staff reviewed. Review of the Nursing Assistant and Licensed Practical Nurse job descriptions indicated that staff are required to complete all assigned training, including that mandated by law and regulation. Personnel file reviews showed that a nurse aide hired in 2000 and an LPN hired in 2020 did not have any documented education regarding resident rights for the current year. The Human Resources Director confirmed that annual training is required, and the Nursing Home Administrator verified that these two staff members had not completed the necessary education on resident rights as required by facility policy and state regulations.
Failure to Provide Resident Rights Training to Staff Member
Penalty
Summary
The facility failed to provide required training on Resident Rights to one of ten staff members, specifically a nurse aide identified as Employee E4. This deficiency was identified through a review of facility education documents and training records, which showed that Employee E4 had not received the mandated education on Resident Rights. During an interview, the Nursing Educator confirmed that this staff member had not been trained as required. The deficiency is cited under 28 Pa Code: 201.14 (a) Responsibility of licensee, 28 Pa Code: 201.18 (b)(1) Management, and 28 Pa Code: 201.20 (a)(6)(d) Staff development.
Failure to Ensure Staff Completion of Resident Rights Training
Penalty
Summary
The facility failed to ensure that staff were educated on resident rights and facility responsibilities, as evidenced by missing or incomplete training documentation for multiple staff members. A personnel file review for an RN hired on August 1, 2024 showed a signed job description requiring participation in all required trainings, but no evidence that this RN had completed Resident Rights training. Review of the in-service training log also did not show Resident Rights training for this RN, and the HR representative confirmed that the Resident Rights course had not been assigned or completed for this staff member at the time of the survey. Similarly, the personnel file for an LPN hired on September 20, 2016 contained a signed Resident's Rights Summary from the date of hire and a signed job description requiring participation in trainings, but there was no evidence of current Resident Rights training. The in-service training log did not show completion of Resident Rights training for this LPN, and HR stated that while the training had been assigned, it was not completed. HR also reported that the training system was responsible for assigning courses and that there were issues with required courses not being assigned or loaded in a standardized way for all staff. Additional staff interviews supported that Resident Rights training was not consistently provided. An LPN reported that staff receive monthly in-services and yearly computer-based training and stated that training on Resident Rights is important so staff can recognize when something inappropriate is occurring and know what to do. A CNA who identified as a relatively new employee stated that although on-the-job training was provided, Resident Rights training had not been provided, and that they were told there would be online training to complete within two months and had only started some Resident Rights training online. The DON stated that the expectation is that staff complete general orientation and periodic education, including Resident Rights, and that lack of such training could lead to a knowledge deficit, delayed responses, and impact care. Facility policy and the facility assessment both identified Resident Rights as a mandatory topic and a required competency to be started during orientation and completed within the first weeks of hire and annually, but the documentation and interviews showed this was not consistently occurring.
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