Failure to Ensure Staff Completion of Resident Rights Training
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.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 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.