Failure to Provide Resident Rights Training to Staff
Summary
The facility failed to provide mandatory training on Resident Rights to eight out of ten staff members, as required by §483.95(b). This deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on March 14, 2025, mandates that all personnel receive education and training related to resident care, including resident rights and responsibilities. However, documentation revealed that several staff members, including nurse aides, registered nurses, a medical records employee, and a dietary employee, did not have documented training on Resident Rights within the specified time frames. The staff members who lacked the required training included Nurse Aides with hire dates ranging from 1995 to 2023, Registered Nurses hired in 2007 and 2022, a Medical Records employee hired in 2010, and a Dietary employee hired in 2017. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide the necessary training on Resident Rights for these employees. This deficiency is in violation of the facility's policy and the regulatory requirements set forth in 28 Pa Code sections related to staff development and management responsibilities.
Plan Of Correction
All nursing staff were provided with Resident Rights training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 0941 was not uploaded to the training platform. Resident Rights has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0942 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
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.
Incomplete Staff Training Documentation: The facility failed to ensure all staff received and had documented mandatory education on resident rights and facility responsibilities. The in-service tracking sheets listed topics and attendance, but did not document the subject matter covered, and the Administrator stated there was no agenda or documentation of the educational material presented during monthly staff meetings.
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 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.
Incomplete Staff Training Documentation
Penalty
Summary
The facility failed to ensure all staff received mandatory training and education related to resident rights and the facility’s responsibilities to care for residents. Review of the Facility Resident Census Roster and Facility Matrix/802 showed 83 residents in the facility. The facility assessment documented staff training and competency and noted that the in-service training calendar indicates mandated annual training requirements and topics pertinent to the provision of care and services to the identified population, but it did not include the amount of time and types of training necessary to meet the rights of residents and responsibilities of the facility to care for residents training requirement. During interview, the Administrator stated that monthly staff meetings were used to provide in-service education and training, that the monthly staff education tracking sheet listed topics and attendance if marked with an X, but that the sheets did not document the subject matter covered. The Administrator also stated there was no agenda followed for the monthly in-services, that topics were provided according to a schedule and delivered from memory, and that the facility did not have documentation of what educational material was presented at the monthly staff meeting or assurance that each staff member received the training.
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