Deficiency in Compliance and Ethics Training for Staff
Summary
The facility failed to ensure that training on written standards, policies, and procedures for the compliance and ethics program was included as mandatory training for direct care staff. This deficiency was identified during a review of staff education records for eight direct care staff members, including nurses and certified nursing assistants. The facility's policy, revised on 3/4/24, mandates that training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. However, the education records for several staff members, including Nurse #8, CNA #1, CNA #7, CNA #4, CNA #11, and CNA #10, did not include the required training on the compliance and ethics program. During interviews, the Staff Development Coordinator (SDC) acknowledged that all education files and records had been provided to the survey team, and confirmed that the facility did not utilize electronic training programs. The SDC, who had been in the role for three months, admitted to trying to catch up on mandatory trainings and confirmed the absence of evidence for the required training in the employee records. The Chief Nursing Officer (CNO) also stated that the mandatory training should be completed upon hire and annually. Despite the SDC's efforts to locate additional records, the survey team did not receive any further documentation by the end of the survey.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Five of five sampled CNAs did not have documented yearly compliance and ethics in-service training. The facility assessment states staff are to receive training upon hire and on a yearly basis, and the NHA confirmed that CNA annual in-service education should include compliance and ethics after reviewing the nurse aide in-service records.
Missing Mandatory Compliance and Ethics Training: The facility failed to ensure an NA completed required compliance and ethics training. Personnel record review showed the training was not completed in the last year, and the DON confirmed the records were not found and expected the training to be completed annually. The facility policy identified ethics training as mandatory, but did not state how often it must be completed.
Missing Compliance and Ethics Training for an LPN: The facility failed to provide required Compliance and Ethics training to one of five direct care staff reviewed. Record review showed an LPN hired on 8/1/24 had no documented Compliance and Ethics training in the past year of employment, and the IP confirmed the omission during interview.
Missing Compliance and Ethics Training Documentation: Record review showed that three CNAs did not have documented evidence of required annual compliance and ethics training in their employee files. The Staff Educator stated she had developed a training program after her hire, but HR later acknowledged the facility could not provide the missing training records.
Failure to provide required Compliance and Ethics training for an NA. Facility policy required annual training, but the NA’s personnel file did not show the required in-service training during the review period. HR confirmed the training was not provided.
Staff failed to document compliance and ethics training for two of six employees reviewed, including two CNAs. During the survey, the administrator could not provide evidence of the required training, and the DON and regional director confirmed that all staff should have compliance and ethics training.
Missing Annual Compliance and Ethics Training for CNAs
Penalty
Summary
The facility did not include an effective way to communicate the standards, policies, and procedures of its compliance and ethics program through a training program for 5 of 5 CNAs randomly sampled. CNA J, CNA K, CNA L, CNA M, and CNA N did not receive and have documented yearly compliance and ethics in-service training. The Facility Assessment, last reviewed 1/2026, states that staff will be provided training and education upon hire, routinely on a yearly basis, and as needed, and lists training topics including communication, resident rights, abuse, infection control, and culture change. During an interview on 7/02/26 at 1:00 PM, the NHA reviewed the Nurse Aide In-Service Records for the five CNAs and confirmed that yearly CNA in-service/education should include compliance and ethics.
Missing Mandatory Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that staff completed mandatory compliance and ethics training for 1 of 10 staff members reviewed, nursing assistant (NA)-J. Review of personnel records showed that NA-J had not completed education that included compliance and ethics in the last year. During an interview, the DON was informed that compliance and ethics training records for NA-J were not found in the records provided, and the DON stated that she expected the training to be completed annually. The DON stated she would provide any additional records if found, but no additional records showing NA-J had completed compliance and ethics training in the last year were received. The facility's undated Staff Development Program policy stated that all personnel must participate in initial orientation and regularly scheduled in-service training classes, and that ethics training was a mandatory in-service training class, although it did not specify how often it must be completed.
Missing Compliance and Ethics Training for an LPN
Penalty
Summary
The facility failed to provide Compliance and Ethics training to one of five direct care staff reviewed, an LPN with a hire date of 8/1/24. Review of the LPN’s personnel file showed that the education training records did not include Compliance and Ethics training during the past year of employment as required. During an interview on 6/3/26 at 10:30 a.m., the Infection Preventionist confirmed that the facility failed to provide Compliance and Ethics training to one of five direct care facility staff.
Missing Compliance and Ethics Training Documentation
Penalty
Summary
The facility failed to ensure staff received compliance and ethics training, as evidenced by record reviews and staff interviews during the annual survey. A review of the employee files for three CNAs showed no documented evidence that compliance and ethics training had been completed in 2025. During an interview, the Staff Educator stated she had developed a training program since her hire in December 2025 to meet annual training requirements, and the surveyor informed both the Staff Educator and HR of the missing training records. On the following day, HR acknowledged the facility was unable to provide documented evidence of the required annual compliance and ethics training for the three CNAs.
Failure to Provide Required Compliance and Ethics Training
Penalty
Summary
The facility failed to provide annual Compliance and Ethics training for one of three staff members, a Nurse Aide (NA) identified as Employee E3. Facility policy on Continuing Education stated that compliance with the facility’s standards, policies, and procedures is a condition of employment, including compliance with the training program, and the policy on Training Requirements-Compliance and Ethics Committee Training stated that the facility must include annual training of the compliance and ethics program. Review of Employee E3’s personnel record showed a hire date of 4/5/24, and the current personnel file did not contain annual in-service training on Compliance and Ethics for the period from 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed that the facility failed to provide Compliance and Ethics training for Employee E3.
Missing Compliance and Ethics Training for Two CNAs
Penalty
Summary
Staff failed to ensure that compliance and ethics training was documented for two of six employees reviewed, identified as CNA #7 and CNA #8. During the extended survey on 5/14/26, the facility administrator was asked to provide evidence of training for the sampled employees, and review of the training records for CNA #7 and CNA #8 showed no evidence that compliance and ethics training had been received. On 5/15/26 at 2:06 PM, the DON and regional director were interviewed and confirmed that all staff should have training on compliance and ethics.
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