F0949

D

Lack of Documented Dementia Care Training for Multiple Clinical Staff

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 and had documented Dementia Care training as required by the facility assessment and staff development expectations. Surveyors requested personnel files and proof of Dementia Care training for several staff, and for five staff members there was no clear evidence that such training had been completed. Personnel files commonly contained signed job descriptions and orientation acknowledgements stating that staff would participate in required trainings, but these documents did not specify that Dementia Care training had been provided or completed.

For a registered nurse hired in August 2024, the personnel file included a job description and a new employee orientation acknowledgement, but no documentation of Dementia Care training. The in-service training log and the electronic training system also did not show assigned or completed Dementia Care training for this RN during the survey. After survey exit, the facility submitted a Clinical Staff Annual Education roster listing this RN’s typed name with a handwritten check mark next to a Dementia and Managing Behaviors to Prevent Abuse topic, but there was no indication of the actual date the training was completed. A similar pattern was found for an LPN hired in 2016: the personnel file and in-service binder lacked evidence of completed Dementia Care training, and although the training system showed Dementia Management training assigned, it was not completed at the time of review. The same Clinical Staff Annual Education roster later submitted also listed this LPN with a handwritten check mark but without a clear completion date.

For a CNA hired in February 2025, the personnel file contained a job description and orientation acknowledgement, but neither specified Dementia Care content, and there was no documentation of Dementia Care training in the training system or in-service binder. For another LPN hired in 2019 and an RN hired in February 2025, personnel files, orientation documents, the training system, and in-service logs similarly lacked any documented Dementia Care training. In each of these cases, the post-survey Clinical Staff Annual Education roster showed the staff member’s typed name and a handwritten check mark for Dementia-related education, but without any clear indication of when the training was actually completed. Staff interviews corroborated gaps in Dementia Care training: an LPN reported that training is provided via monthly in-services and yearly computer-based modules and emphasized the importance of Dementia Care training, while a CNA described receiving on-the-job training but no Dementia Care training and being told there would be online training to complete within two months. The DON stated that staff are expected to complete general orientation and periodic education, and that Dementia Care training is important to prevent knowledge deficits. The facility’s Staff Development Program policy required initial orientation and regular in-services but did not specifically mention Dementia Care, while the facility assessment stated that Dementia training was part of staff competencies to be started during orientation and completed within the first weeks of hire and annually.