Failure to Maintain Compliance and Ethics Committee
Summary
The facility failed to adhere to its Compliance and Ethics Program by not having a compliance committee that meets quarterly, as required by its own policies and procedures. The facility's Compliance Policies and Procedures, dated October 29, 2017, mandate the establishment of a compliance committee that includes key personnel such as the Administrator, Director of Nursing (DON), Social Services Director (SSD), Director of Admissions, Minimum Data Set Coordinator, and Corporate Compliance Officer. However, interviews with staff members revealed a lack of awareness and participation in such meetings. The DON, who served as the facility's administrator for several months in 2024, was unaware of the Compliance and Ethics Program or committee and mistakenly believed compliance was addressed during Quality Assurance meetings. Further interviews with the SSD, who has been in the role since March 2024, confirmed the absence of Compliance and Ethics committee meetings. The SSD reported that concerns were typically filed as grievances for follow-up, rather than being addressed in a structured committee setting. A review of the Quality Assurance meeting minutes from January, April, July, and October 2024 showed no mention of the Compliance and Ethics Program or committee, indicating a systemic oversight in maintaining the required compliance structure. This deficiency potentially affects all 73 residents residing in the facility, as documented in the Long-Term Care Facility Application for Medicare and Medicaid dated October 27, 2024.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA with a recent conviction for domestic violence, a disqualifying offense under state law, continued to provide direct care to all residents after the conviction. Facility leadership was aware of the conviction but allowed the CNA to work, citing personal character standards, despite not meeting the required time elapsed since probation discharge. This action was not in compliance with state regulations or facility policy.
Failure to Remove CNA Convicted of Disqualifying Offense
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA) who had been convicted of a disqualifying offense, specifically first-degree misdemeanor domestic violence, did not continue to provide direct care to residents. Personnel records, background check logs, and court documents confirmed that the CNA was arrested and later convicted of domestic violence. Despite this conviction, which is listed as a disqualifying offense under Ohio Administrative Code, the CNA continued to work in the facility and provide direct care to residents. The review of staff schedules showed that the CNA worked multiple shifts after the conviction date, while still on probation for the offense. Interviews with the Human Resources Director and the interim Administrator revealed that both were aware of the conviction but allowed the CNA to continue employment, citing the use of personal character standards. However, the CNA did not meet the specific requirement that at least five years must have elapsed since being fully discharged from probation for an offense of violence, as outlined in the relevant state regulations. Facility policy and the staff handbook clearly state that conviction of a relevant criminal offense may result in termination, and that staff are responsible for reporting such convictions. The facility's own documentation and interviews confirmed that the CNA's continued employment was not in compliance with state law or facility policy, as the CNA had access to all residents during this period despite the disqualifying conviction.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
