Failure to Provide and Document Required Abuse and Elder Justice Act Training for Staff and NA Student
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure timely initial abuse prevention training for two newly hired staff members, including a Cook and a Dietary Aide. Personnel records showed both employees completed required orientation training late, and the HR Director confirmed the delay. The facility policy required new staff orientation to include abuse prohibition practices, reporting, and what constitutes abuse, neglect, and misappropriation of resident property.
The facility failed to provide required abuse, neglect, exploitation, and misappropriation training, including all seven components of its Abuse Prohibition Program, to two newly hired direct-care staff. Personnel file reviews showed no documentation of this training at orientation, and both a CNA and a nurse aide reported they had not received abuse and neglect education. The staffing coordinator stated that orientation only covered reporting abuse and neglect, not screening, prevention, identification, investigation, protection, or response, and acknowledged staff might not know what is reportable. The administrator and DON believed new staff were receiving comprehensive abuse training but did not attend orientation and were unaware that in-depth training was not being provided.
Failure to Provide Required Abuse, Neglect, and Exploitation Training: The facility did not have credible annual in-service training on abuse, neglect, and exploitation for five staff members, including NAs, an RN, and an LPN. Personnel files lacked documentation of the required training, and the NHA confirmed the lapse during interview.
Missing Required Abuse and Dementia Training for CNA: The facility failed to ensure a CNA completed required annual training on abuse, neglect, exploitation, and dementia management. Record review showed the CNA’s training was not completed, and HR and the Administrator confirmed there was no evidence of the required annual in-service training in the file. The facility policy required staff training on abuse prevention, reporting procedures, and dementia management.
Failure to Provide Required Abuse, Neglect, and Exploitation Training: The facility failed to document annual in-service education on abuse, neglect, exploitation, and dementia care for an LPN, an RN, and three NAs. Facility policy required regular staff training on these topics, but personnel files did not show the required annual education, and the NHA confirmed there was no employee education for the year reviewed.
Staff interviews and record review showed that multiple CNAs and an LVN did not know who the facility’s Abuse Coordinator was or which external agencies must receive abuse allegations within the required two-hour timeframe. The DSD stated that the Administrator is the Abuse Coordinator and that all staff are expected to know to report suspected abuse to the Administrator, who then reports to the state survey agency, APS, law enforcement, and the Ombudsman. The facility’s written abuse prevention policy confirms these responsibilities and timelines, yet interviewed staff were unable to identify the Abuse Coordinator or the mandated reporting entities.
Late Abuse Prevention Training for New Employees
Penalty
Summary
The facility failed to ensure elder abuse prevention training was completed timely for 2 of 18 sampled employees, Employee #16 and Employee #17. Employee #16 was hired as a Cook with a start date of 11/19/2025, and the personnel record showed elder abuse prevention training was completed on 11/28/2025, 9 days late. Employee #17 was hired as a Dietary Aide with a start date of 12/15/2025, and the personnel record showed elder abuse prevention training was completed on 12/31/2025, 16 days late. During an interview on 04/22/2026 at 1:45 PM, the HR Director stated all staff were required to take initial elder abuse prevention training upon hire and confirmed both employees completed the training late. The facility policy titled Freedom from Abuse/Abuse Prohibition, revised 01/19/2026, stated employees would receive orientation upon hire to include training on abuse prohibition practices, including appropriate interventions, reporting, signs of burnout, frustration and stress, and what constitutes abuse, neglect, and misappropriation of resident property.
Failure to Provide Required Abuse and Neglect Training to New Staff
Penalty
Summary
The facility failed to provide required training on abuse, neglect, exploitation, misappropriation of resident property, and the reporting and prevention of such incidents to two staff members. Facility policy, dated 03/2025, required that all staff be trained on the Abuse Prohibition Program during orientation, annually, and on an ongoing basis, and specified seven components: screening, training, prevention, identification, investigation, protection, and reporting/response. Review of CNA B’s personnel file, with a hire date of 03/27/26, showed no documentation that this abuse and neglect training, including the seven required components, was provided during orientation. In an interview, CNA B stated he/she did not receive orientation upon hire and did not receive abuse and neglect training. Similarly, review of NA C’s personnel file, with a hire date of 04/02/26, showed no documentation of abuse and neglect training that included the seven required components during orientation. In an interview, NA C confirmed he/she did not receive abuse and neglect training. The staffing coordinator reported that during orientation he/she only educated staff to report abuse and neglect, and did not cover screening, training, prevention, identification, investigation, protection, and response to abuse and neglect, and acknowledged that if staff did not know what qualifies as abuse and neglect, they might not know what is reportable. The administrator and DON each stated that new staff should receive or did receive comprehensive abuse and neglect training including all seven components, but both acknowledged they did not attend orientation sessions and were unaware that the staffing coordinator was not providing in-depth training as required by facility policy.
Failure to Provide Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide training on Abuse, Neglect, and Exploitation for five of five staff members: NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8. Review of the facility's In-Service Training Program policy indicated that nurse aide personnel are to participate in regularly scheduled in-service training classes, with notices posted on the employee bulletin board at least seven days before the class and attendance entered on each employee's Record of In-Service by the department supervisor or designee. Review of personnel files showed that NA Employee E4, hired 3/20/24; NA Employee E5, hired 10/22/19; RN Employee E6, hired 5/30/19; LPN Employee E7, hired 10/19/15; and NA Employee E8, hired 3/9/81 did not have credible annual in-service training on Abuse, Neglect, and Exploitation from 1/1/25 through 12/31/25. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide this training for all five staff members.
Missing Required Abuse and Dementia Training for CNA
Penalty
Summary
The facility failed to ensure that CNA E received required annual training on Abuse, Neglect, and Exploitation and dementia management. Record review showed CNA E was hired on 06/29/2024, and there was no evidence that the required annual training had been completed since her hire date. Electronic training records showed the training was initiated by CNA E on 4/15/2026 but was not fully completed after the survey team entered the facility on 04/13/2026. During interview, the HR staff member stated she was new to her position and was responsible for completing orientation and other paperwork, and she was not aware that CNA E had not completed the assigned training on Abuse, Neglect, and Exploitation and dementia management during annual training for 2025. The Administrator later reviewed the training file for CNA E and found no evidence of the required annual training. The facility policy revised 02/2026 stated that all personnel must participate in initial orientation and regularly scheduled in-service training, including training on preventing abuse, neglect, exploitation, misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention.
Failure to Provide Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide annual training on Abuse, Neglect, and Exploitation for five of five staff members reviewed: one LPN, one RN, and three NAs. The facility policy for In-Service Training, All Staff dated 2/11/26 required regular in-service education for all staff, including training on preventing abuse, neglect, exploitation, and misappropriation of resident property, as well as dementia management and resident abuse prevention. The policy also stated training must be completed before staff provide care, annually, and as needed based on the facility assessment, with documentation maintained by the staff development coordinator or designee. During interviews, the NHA stated the facility had recently made staff complete education and later acknowledged there was no employee education for 2025. Review of the personnel files showed no annual in-service training on Abuse, Neglect, and Exploitation for the LPN, RN, and three NAs for the 1/1/25 through 12/31/25 period. The facility did provide education test packets for four staff members, and two packets for one NA were signed but undated, but the files still did not include the required annual training documentation. The NHA confirmed the facility failed to provide the required training for all five staff members.
Staff Lack Knowledge of Abuse Reporting Roles and Requirements
Penalty
Summary
The facility failed to ensure that staff understood and followed its abuse reporting policies and procedures. During interviews, three of six sampled staff members (two CNAs and one LVN) were unable to identify the facility’s Abuse Coordinator and did not know the external agencies to which allegations of resident abuse must be reported. Specifically, these staff members did not know that allegations of abuse must be reported to the California Department of Public Health, the Ombudsman, adult protective services, and local law enforcement within two hours when abuse is suspected. The Director of Staff Development stated that the Administrator is the Abuse Coordinator and that all staff are expected to know this and to understand the reporting requirements. The record review included an admission record and history and physical for a resident admitted with schizophrenia, impulse disorder, and hypertension, with documentation that the resident lacked capacity to understand and make decisions due to schizophrenia. The facility’s written policy, “Abuse Prevention and Prohibition Program,” revised 11/28/2022, states that the Administrator or designee serves as Abuse Coordinator and is responsible for reporting known or suspected abuse to proper authorities, and that staff must report suspected abuse to the Administrator or designee. The policy further specifies that allegations of abuse must be reported immediately, but no later than two hours after suspicion is formed, to the state survey agency, adult protective services, law enforcement, and the Ombudsman. Despite these written requirements, interviewed staff demonstrated a lack of knowledge of both the designated Abuse Coordinator and the mandated external reporting entities and timelines.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
