Failure to Develop and Implement Compliance and Ethics Program
Summary
The facility failed to develop and implement a compliance and ethics program, as well as to provide staff with compliance and ethics training. Interviews with the Administrator and two Regional RNs revealed that there was no compliance and ethics program or policy in place, and that such training was not included in new hire orientation or annual training. Although a Code of Conduct policy existed, it was not communicated to all facility staff and did not include essential components such as identification of a compliance officer or committee, procedures for reporting ethical concerns, secure and confidential reporting mechanisms, internal monitoring and auditing, or processes for response and corrective action. The Director of Nursing Services was unavailable for interview, and the requested compliance and ethics policy was not provided.
Penalty
Resources
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The facility failed to provide annual Compliance and Ethics training for five staff members, including NAs, an RN, and an LPN. Review of personnel files showed no credible in-service training for the required period, and the NHA confirmed the lapse during interview.
Failure to provide required Compliance and Ethics training for an LPN, an RN, and three NAs. Facility policy required regular in-service education for all staff, including annual compliance and ethics training documented with the date, topic, competency assessment, and hours completed. Personnel files did not show the required annual training for the five staff members, and the NHA stated there was no employee education for the year and confirmed the lapse.
Facility staff did not ensure that required annual compliance and ethics training was completed for two CNAs. The staff development coordinator reported that staff education was assigned via an annual competency calendar and that staff had the full year to complete required modules, but she could not produce documentation showing that these CNAs had completed the compliance and ethics training. Facility documents, including the facility assessment and an in-service training policy, specified that all staff must receive annual education on corporate compliance, ethics, and the compliance and ethics program standards, policies, and procedures.
Missing Compliance and Ethics Training for CNA. The facility failed to include compliance and ethics training in its program and failed to ensure a CNA received required training upon hire. Record review showed the CNA had no evidence of completing the CBT or any in-service on compliance and ethics, and both the ADMN and HR confirmed there was no documentation of the training. The 2025 facility assessment listed staff training topics but did not mention compliance and ethics.
Missing Compliance and Ethics Training for Staff: The facility failed to provide evidence that a speech and language pathologist completed required compliance and ethics training. Surveyors requested the record, but HR documentation did not show completion. The HR Director stated she relies on third-party training notifications and does not personally verify which trainings are required by regulation. The onboarding curriculum included online required training for Compliance and Code of Conduct.
Missing compliance and ethics training was identified after record review and DON interview. The facility assessment listed compliance and ethics as a required staff training topic, but the files for two GNAs and an LPN showed no evidence of the required annual training. The DON acknowledged that the annual training had not been completed for those staff members.
Missing Compliance and Ethics Training for Five Staff Members
Penalty
Summary
The facility failed to provide training on Compliance and Ethics 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 for nurse aides indicated that staff are to participate in regularly scheduled in-service training classes and that attendance is to be entered on the employee's Record of In-Service by the department supervisor or other designated person. Review of the personnel files for the five employees showed dates of hire ranging from 1981 to 2024, but none of the files contained credible annual in-service training on Compliance and Ethics for the period 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 Compliance and Ethics training for these five staff members.
Failure to Provide Required Compliance and Ethics Training
Penalty
Summary
The facility failed to provide annual training on Compliance and Ethics for five of five staff members: one LPN, one RN, and three NAs. Facility policy required all staff to participate in regular in-service education, including compliance and ethics training, with training completed prior to providing care, annually, and as needed based on the facility assessment. The policy also required completed training to be documented by the staff development coordinator or designee, including the date and time of training, topic, competency assessment summary, and hours completed. Review of personnel files showed that the LPN, RN, and three NAs did not have annual in-service training on Compliance and Ethics documented for the period from 1/1/25 through 12/31/25. The facility provided education test packets for four of the five staff members, and for one NA the packets were signed but undated. During interviews, the NHA stated that there was no employee education for 2025, that the previous HR employee did not do the job correctly, and that after the prior employee left on March 1, the facility reviewed education records and realized there was none. The NHA confirmed that the facility failed to provide training on Compliance and Ethics for the five staff members.
Failure to Ensure Completion of Required Compliance and Ethics Training
Penalty
Summary
Facility staff failed to ensure completion of required compliance and ethics training for two of eight employees reviewed, specifically CNA #9 and CNA #10. During an interview, the staff development coordinator reported that she began working at the facility in December 2025 and that there was an annual competency calendar assigning education throughout the year, with staff given until December 31 each year to complete required assignments. She also stated she had an ongoing performance improvement plan to address missed education that was not yet completed. Upon request, the staff development coordinator was unable to provide any evidence that CNA #9 and CNA #10 had completed the required compliance and ethics training. The facility assessment dated 2/26/2026 documented that all staff annual education course topics included corporate compliance and ethics, and the facility’s “In-Service Training, All Staff” policy dated 2001 stated that all staff are required to participate in regular in-service education, including required training on the compliance and ethics program standards, policies, and procedures, to be conducted annually when the organization operates five or more facilities. On 4/9/2026 at approximately 11:12 AM, the administrator, DON, vice president of operations, regional director of clinical services, assistant DON, and clinical consultant were informed of the concern, and no additional information was provided before survey exit.
Missing Compliance and Ethics Training for CNA
Penalty
Summary
The facility failed to include compliance and ethics training as part of its compliance and ethics program, including an effective way to communicate the program's standards, policies, and procedures through training or another practical method. The report states that the facility also failed to provide annual training for all new and existing staff for an organization operating 5 or more facilities, and this was identified for 1 of 18 staff reviewed, CNA F. Record review showed CNA F was hired on 12/30/2025 and had no evidence of completing compliance and ethics training upon hire or while working at the facility. During interviews, the ADMN stated she expected staff to receive appropriate training per regulations, said the facility did not have a training policy and relied on regulations for orientation and annual training, and confirmed she could not find CNA F's signature on any in-service record or evidence in the CBT program. The HR stated she was responsible for ensuring staff completed CBT training, was new to the position, and had no evidence that CNA F completed compliance and ethics training. The facility assessment for 2025 listed training topics for staff, including direct care staff, but did not mention compliance and ethics training.
Missing Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to provide evidence of required compliance and ethics training for one of ten staff records reviewed, OSM #3, a speech and language pathologist. On 2/20/26, surveyors requested evidence of the training, and the facility records provided by the Director of Human Resources did not show that the training had been completed. During an interview on 2/24/26, the Director of Human Resources stated that new employees receive a list of required trainings through a third-party education provider, that the trainings are completed online, and that she transfers completion records to another third-party software after completion. She also stated that she does not personally verify which trainings are required for each employee and does not keep up with which subject matter trainings are required by regulations. A review of the facility's onboarding curriculum for all staff showed an online required training for Compliance and Code of Conduct.
Missing Compliance and Ethics Training for Staff
Penalty
Summary
Failure to ensure staff received compliance and ethics training was identified during the annual survey after administrative record review and staff interview. The DON stated that nursing skills competencies are verified at orientation and reassessed annually, and that the facility uses Relias for required monthly and annual training. Review of the facility assessment approved in January 2026 showed that staff training requirements included abuse, neglect and exploitation, infection control, dementia management, QAPI, and compliance and ethics. However, review of the employee files for GNA #36, GNA #37, and LPN #38 showed no evidence of compliance and ethics training. When the DON was asked about the missing 2025 compliance and ethics training for these three employees, the DON acknowledged that the required annual training had not been completed in 2025.
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