Deficiency in Compliance and Ethics Program
Summary
The facility failed to maintain an effective compliance and ethics program, as evidenced by an incident involving a registered nurse (RN) and a licensed practical nurse (LPN). On two occasions, the facility's narcotic documentation forms were missing signatures, indicating a lack of proper verification of controlled substance counts. On May 28, 2024, RN-D instructed LPN-E to sign a narcotic documentation form for a count he did not witness. This action was stopped by a surveyor, highlighting a breach in protocol. The facility's policy requires two nurses or medication aides to verify and sign off on narcotic counts at each shift change, which was not adhered to in this instance. Further investigation revealed that RN-D lacked documentation of ethics training upon hire, despite a facility policy requiring such training. Additionally, the facility did not have an active ethics committee, and the director of nursing (DON) was unaware of any regular meetings or the existence of such a committee. The facility's policies emphasize accurate documentation and ethical conduct, yet these were not followed, leading to the deficiency noted by the surveyors.
Penalty
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A facility failed to maintain an effective compliance and ethics program with adequate monitoring and auditing of MDS data and did not ensure staff could report suspected misconduct without fear of retaliation. Multiple residents had inconsistent or unsupported F33.3 diagnoses added, modified, or removed in the EMR and MDS, while provider notes and orders did not consistently support the diagnosis. Staff reported concerns about altered faxed orders, audit trail changes made by the DON and corporate nurses, and fear of retaliation when raising the issue.
Failure to maintain an effective compliance and ethics program: residents and staff reported the DON yelled at employees, discussed residents inappropriately, and created fear of retaliation, while staff described underreporting, altered statements, and instructions to cover up incidents. Several employees were unfamiliar with the compliance hotline or unsure how to use it, and the NHA acknowledged staff concerns but did not report them to corporate leadership.
Compliance Program Failed to Promote Honest Documentation and Ethical Recordkeeping: Survey findings showed a manipulated census that obscured a mixed-gender room arrangement between two residents, incomplete transfer and room-change documentation for a resident returning from the hospital, and DON-directed editing of e-records. LNs and IDT members stated the DON routinely left records unlocked to edit change-of-condition documentation, add notes, and make it appear team members were present when records were created.
Inaccurate medication administration documentation was found for two residents. One resident’s nebulizer treatment was documented as given even though an LPN said it was not administered because the resident was in activities. Another resident’s eye ointment was documented as administered on the EMAR, but an LPN stated the medication never arrived at the facility and the charting was inaccurate. The DON stated nurses were expected to document accurately and not falsely document in the medical record.
The facility failed to enforce its compliance and ethics program when an Administrator allowed a Dietary Manager to work with vulnerable residents before a background check was completed. Although policy required criminal screening before hire and before unsupervised resident contact, the staff member was working while the BGI remained pending. The HRD stated this was not the normal process, and the DON and DCO said staff should not work with vulnerable residents until screening was complete.
Compliance and Ethics Program Not Effectively Implemented: The NHA was not aware she was the designated Compliance Liaison and did not recall training on the facility’s Ethics and Compliance program. She was unfamiliar with the procedures, was not aware of any reported violations, and had not been involved in written standards, staff education, internal monitoring, enforcement of disciplinary guidelines, or communication with staff regarding the compliance hotline and reporting process.
Compliance Program and MDS Documentation Irregularities
Penalty
Summary
The facility failed to implement an effective compliance and ethics program with sufficient monitoring and auditing mechanisms to detect and prevent potential violations and to ensure the integrity of data reported to CMS. The facility also failed to ensure employees could report suspected violations by a high-level leader without fear of retaliation. These failures were associated with documentation and MDS irregularities involving unsupported or inconsistently reported diagnoses for four residents reviewed: R31, R39, R40, and R61. For R31, the admission record identified an admission date of 1/25/23, but the quarterly MDS did not contain diagnosis code F33.3 in Section I. RN-A later modified the MDS to add F33.3, and the diagnosis audit report showed the diagnosis had been added to the EMR with an effective date of 1/25/25. However, a provider progress note from 4/21/26 did not include F33.3 and instead documented severe Lewy body dementia with agitation and depressive disorder in remission. The resident’s progress notes did not reflect supporting documentation for the F33.3 diagnosis, and a provider order for that diagnosis was requested but not received. For R39, the significant change in status assessment MDS completed by RN-A included F33.3, but the history and physical dated 8/13/23 identified late onset Alzheimer’s disease without behavioral disturbance and generalized anxiety disorder, not F33.3. The diagnosis audit report showed F33.3 was added to the record with an effective date of 8/17/23, and a provider order for F33.3 was requested but not received. For R40, the SCSA MDS initially did not identify F33.3, then RN-A added it through a modification and RN-B later removed it. The diagnosis audit report showed F33.3 was added to the EMR with an effective date of 1/15/25. A physician update facsimile dated 8/17/25 referenced use of F33.3 related to behaviors, agitation, and trazodone use, but the provider progress note from 3/24/26 did not include F33.3 and instead documented mild late onset Alzheimer’s dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. NP-F stated she was not aware either R40 or R39 had the diagnosis and confirmed it was not on their current or historical diagnosis lists.
Failure to Maintain an Effective Compliance and Ethics Program
Penalty
Summary
The facility failed to effectively implement its compliance and ethics program by not promoting ethical conduct related to reporting resident incidents and allegations of abuse, not providing effective oversight by high-level personnel to ensure adherence to ethical standards, and not maintaining effective lines of communication that encouraged staff and residents to report concerns without fear of retaliation. During interviews, residents stated the DON yelled at staff, discussed other residents in front of residents and visitors, and that some residents feared retaliation and therefore did not report concerns. One resident also reported that staff were disrespectful toward Spanish-speaking residents. Staff interviews reflected similar concerns. An LPN stated management changed staff statements, claimed they were unaware of reported incidents, and that the facility was underreporting incidents. The LPN said the DON instructed staff what to write to cover up incidents, that medications were documented as administered when they were not available, and that staff were required to contact the DON before initiating CPR, which could delay care. An RN stated the DON insulted her, made comments about Hispanics, screamed and yelled at staff, and that residents had videotaped the DON yelling at her. A CNA stated she was unaware of the ethics and compliance hotline and believed concerns should be reported to HR, while another CNA stated she feared losing her job if she reported concerns and had instead gone to Social Services when residents voiced concerns. The NHA acknowledged staff had expressed concerns about the DON's harsh and rough interactions with staff, but said she addressed them directly with the DON and acted as a mediator; she had not reported those concerns to corporate leadership. The NHA stated staff received ethics and compliance education upon hire and annually and could report concerns to her or the corporate hotline, but she was unaware that staff or residents feared retaliation. The Corporate Compliance Officer stated the hotline accepted anonymous and identified reports, concerns could also be submitted by QR code, and employees received annual ethics and compliance training, but the report also showed staff were unfamiliar with the hotline and the facility's ethics and compliance program. The facility's compliance poster and policies stated employees were expected to report illegal or unethical issues and that the program included open lines of communication and reporting suspected ethical misconduct.
Compliance Program Failed to Promote Honest Documentation and Ethical Recordkeeping
Penalty
Summary
The facility failed to maintain its compliance and ethics program when it did not promote honest and ethical behavior in work-related activities. Survey findings identified false medical records and reports, including a manipulated resident census that obscured an overnight mixed-gender room arrangement between a male resident and a female resident. The census showed the male resident transferred to the hospital on 6/2/26 and the female resident admitted that evening, then showed the male resident returning at 3:20 a.m. on 6/3/26 and being placed in a bed while the female resident’s bed was listed as vacant after she was moved later in the day. Progress notes documented that curtains were drawn for privacy, and staff interviews confirmed both residents occupied the same room during the evening and overnight shifts until they were relocated during the day. Record review also found incomplete documentation related to the male resident’s transfer and room changes. The registered nurse supervisor stated that charge nurses were expected to complete the written 7-day bed hold notice during hospital transfers, but no bed hold notice was found for the resident. The supervisor was also unable to produce a room change notification for the resident’s return from the hospital on 6/3/26, and only a later room change notification dated 6/4/26 was available after a second room relocation occurred. Additional interviews and record review showed that the Director of Nursing instructed licensed nurses to leave electronic records saved but unlocked so the DON could edit them and complete resident change-of-condition documentation according to the DON’s standards. Licensed nurses confirmed this practice, and interdisciplinary team members stated the DON routinely edited change-of-condition records, entered notes and recommendations, and added the names of team members so it appeared they were present when the records were created. The administrator stated there was no documentation of the resident’s room changes on 6/3/26 and that the mixed room arrangement was not normal practice, while the DON stated the multiple room changes from 6/2/26 to 6/4/26 were necessary to meet resident and facility needs.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation related to medication administration for two residents. One resident, admitted with diagnoses including metabolic encephalopathy, asthma, chronic respiratory failure with hypoxia, and COPD, had an EMAR entry showing Ipratropium-Albuterol nebulizer treatment documented as administered at 1500, but an LPN later stated she did not give the treatment because the resident was in activities. This created a discrepancy between the medication record and the nurse’s account of what occurred. A second resident, admitted with diagnoses including Parkinson’s disease, type 2 diabetes mellitus with hyperglycemia, vascular dementia, and anxiety, had an order for Bacitracin ophthalmic ointment for a sty in the left eye. The EMAR showed the medication as administered on multiple dates, but administration notes stated the medication was on order or awaiting pharmacy delivery. During interview, an LPN stated the medication never arrived at the facility and that documentation showing it was given was inaccurate. The DON stated nurses were expected to document according to policy and not falsely document in the medical record, and the facility stated it did not have a documentation policy for this citation.
Failure to Enforce Background Check and Compliance Procedures
Penalty
Summary
The facility failed to implement, maintain, and enforce an effective compliance and ethics program with monitoring and auditing systems related to abuse screening and hiring practices. The report states that the facility’s policies required criminal background checks for all employees before hire and prohibited staff from working with vulnerable residents until screening was completed, but these procedures were not followed for a Dietary Manager who was hired while the background inquiry was still pending. Record review showed the Dietary Manager’s background inquiry was submitted before hire but had not been completed. During interviews, the Dietary Manager stated the Administrator knew the background check was still in process and approved them to work anyway. The Administrator confirmed the staff member was working in the facility without a current completed background check and stated they trusted the staff member and did not think supervision was necessary while the check was pending. The Human Resources Director stated the normal process was to complete the background check before a new staff member worked unsupervised with vulnerable residents, and that this was not the normal process in this case. The Human Resources Director also stated the Administrator made the decision to let the staff member work without the completed background check. The DON and Director of Clinical Operations stated new staff should not work with vulnerable residents until the background check was completed and were not aware the Administrator had approved the staff member to work unsupervised while the background inquiry remained pending.
Compliance and Ethics Program Not Effectively Implemented
Penalty
Summary
The facility failed to implement policies and procedures to ensure an effective Compliance and Ethics program. During an interview, the Regional Nurse stated that the parent organization had a corporate director of compliance and that staff could report suspected violations to a hotline. The Nursing Home Administrator stated she did not recall having training on the facility Ethics and Compliance program, thought online training was scheduled yearly, and believed postings for the hotline were in common areas. She identified possible reportable issues as HIPAA/privacy concerns, resident care concerns, and staffing concerns, but said she was not aware of any reported violations and had not responded to any alleged violations. The Nursing Home Administrator was not aware of who the facility Compliance liaison was and was not familiar with the procedures, stating she would review the policy and find out. A policy provided to surveyors was dated 11/01/2019, while a later policy dated 12/09/2024 stated the facility had a Corporate Compliance and Ethics Program, designated a compliance contact, and described reporting methods, audits, and the administrator’s responsibility for maintaining compliance documentation. In an email after the interview, the Nursing Home Administrator confirmed she was the Compliance Liaison, but prior to that she had not been aware she was designated in that role and therefore was not involved with written standards, training, internal monitoring, enforcement of disciplinary guidelines, communication with staff, or participation in a compliance committee.
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