F0943

E

Failure to Provide and Document Required Abuse and Elder Justice Act Training for Staff and NA Student

Lakeside, Arizona Survey Completed on 11-19-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that multiple staff members received required education on abuse, neglect, exploitation, and the Elder Justice Act, as well as failure to ensure one staff member received abuse education and one NA student received Elder Justice Act training. Surveyors requested personnel files and proof of abuse and Elder Justice Act training for several identified staff and one NA student. For a registered nurse hired in August 2024, the personnel file contained a signed job description and a new employee orientation acknowledgment, but there was no documentation specifying what training was covered, and no evidence in the personnel file, in-service logs, or the training system that abuse or Elder Justice Act training had been completed. Later, a clinical staff annual education roster provided by the facility listed this RN’s typed name with a handwritten check mark, but without any clear indication of when the training was actually completed.

For an LPN hired in 2016, the personnel file showed a Preventing and Reporting Resident Abuse and Elder Justice Act form signed at hire, but there was no evidence of current Elder Justice Act training in the personnel file, in-service logs, or the training system. The HR representative confirmed that the Elder Justice Act course was not indicated in the system for this LPN and acknowledged that required courses were not being consistently assigned or loaded. Similar findings were documented for the activity director, a CNA, another CNA, and an LPN, all of whom had signed job descriptions and orientation acknowledgments that did not specify training content, and none had documented Elder Justice Act training in their personnel files, the training system, or in-service logs. For some of these staff, the facility later produced a clinical staff annual education roster with typed names and handwritten check marks, but again without dates or clear evidence of when or if the Elder Justice Act training was completed, and in some cases the staff member’s name did not appear on any relevant roster.

For another RN hired in February 2025, the personnel file contained a signed job description and orientation acknowledgment, but no documentation of Elder Justice Act training in the file, training system, or in-service binder. HR confirmed the absence of this training and stated that courses would need to be added to the system. Additionally, for an NA student participating in a free CNA class, the facility stated that the individual was not an employee and that only a TB test was on file; items requested as part of a personnel record, including Elder Justice Act training, were not obtained for non-employee participants. There was no documentation of Elder Justice Act training completion for this NA student in the in-service logs or email attachments. Staff interviews supported these findings: one LPN described that training is provided via monthly in-services and yearly computer-based modules and emphasized the importance of abuse training, while a CNA reported receiving on-the-job training but no abuse or Elder Justice Act training and being told that online training would need to be completed later. Facility policies and the facility assessment indicated that abuse, neglect, and exploitation are mandatory topics and that employees are to receive education on the Elder Justice Act during orientation and annual in-services, but there was no specific mention of Elder Justice Act training in the staff development program policy, and the documented training for the cited staff did not align with these expectations.

The facility’s own documents further highlighted inconsistencies between policy and practice. The Staff Development Program policy required all personnel to participate in initial orientation and regularly scheduled in-service training classes and identified abuse as a mandatory topic, but did not reference Elder Justice Act training. The facility assessment stated that competencies, including abuse, neglect, and exploitation, are started during orientation and completed within the first few weeks of hire and then annually, without specific mention of Elder Justice Act. In contrast, the Abuse Policy explicitly required that all employees receive education on the Elder Justice Act, including contact and reporting information, and that education on abuse prevention, recognition, and reporting be provided during new hire orientation, annual in-services, and as needed. The lack of documented training for the cited staff and the NA student, despite these written requirements, formed the basis of the deficiency.

Interviews with HR and leadership corroborated the documentation gaps. HR repeatedly acknowledged during joint reviews with surveyors that the training system had not assigned or loaded Elder Justice Act courses for several staff and that there was no documentation of completion in either the system or orientation records. HR suggested checking in-service binders, which did not show evidence of the required training for the cited staff. The DON stated that the expectation is for staff to complete onboarding orientation covering general education and to receive periodic education throughout the year, and emphasized the importance of abuse and Elder Justice Act training so staff know how to identify, report, and understand residents’ rights. Despite these stated expectations and policies, the survey findings showed that at least one staff member lacked abuse education and multiple staff and an NA student lacked documented Elder Justice Act training, leading to the cited deficiency.