F0940

E

Failure to Provide and Document Required Disaster Training for Multiple Staff

Lakeside, Arizona Survey Completed on 11-19-2025

Penalty

No penalty information released

Summary

The facility failed to ensure that multiple staff members received required Disaster training as part of its staff development and emergency preparedness program. Personnel records and training documentation for four staff members showed no evidence that Disaster training had been completed, despite facility policies and the facility assessment stating that Emergency Preparedness, including Fire and Disaster training, was a mandatory topic and that such competencies were to be started during orientation and completed within the first few weeks of hire and then annually. New Employee Orientation Acknowledgements and signed job descriptions for these staff members referenced participation in required trainings and events but did not specify the content or confirm completion of Disaster training.

For a registered nurse hired in August 2024, the personnel file contained a signed job description and a New Employee Orientation Acknowledgement, but there was no documentation that Disaster training had been completed. Review of the in-service training log and the electronic training system, conducted with the HR representative, confirmed that Disaster training was neither assigned nor completed for this nurse at the time of survey. After survey exit, the facility submitted a Clinical Staff Annual Education roster listing this nurse’s typed name with a handwritten check mark under a training complete section and indicating Disaster as a topic, but the roster did not clearly show when the training was actually completed.

For an LPN hired in 2016, the personnel file similarly lacked evidence of completed Disaster training, although the job description required participation in all required trainings. The HR representative stated that the training system is supposed to assign courses and that Disaster training was assigned to this LPN but had not been completed, and the in-service training log did not show completion. A Clinical Staff Annual Education roster later provided by the facility listed the LPN’s typed name with a handwritten check mark and indicated Elder Justice Act among the topics, but again without clear dates of completion. For a CNA hired in February 2025 and another LPN hired in 2019, personnel files, orientation records, the training system, and in-service logs all lacked documentation of Disaster training. Subsequent rosters submitted after survey exit showed their typed names with handwritten check marks but no clear indication of when the Disaster training was completed.

Interviews with staff further described the facility’s training practices and expectations. The HR representative explained that the electronic training system is responsible for assigning courses and acknowledged that, based on the records reviewed, some courses were not being assigned and that certain staff had no Disaster training documented in either the system or orientation. An LPN reported that staff receive training via monthly in-services and yearly computer-based modules and stated that training on Disaster topics is important so staff know what to do and how to care for residents in such situations. A CNA who identified as a relatively new employee reported receiving on-the-job training but no other training yet, and was told there would be online training to complete within two months. The DON stated that staff are expected to follow facility policy by completing general orientation and periodic education throughout the year, and emphasized that Disaster training is important so staff know how to evacuate and respond in emergencies and be prepared to protect residents, noting that lack of training could lead to a knowledge deficit and delayed responses that impact care.