Deficiency in Staff Compliance and Ethics Training
Summary
The facility failed to ensure that all staff received their annual training for the compliance and ethics program, as evidenced by the lack of documentation for five out of nine staff members reviewed during the Extended Survey investigation portion of the recertification/complaint survey. Interviews and record reviews revealed that the Director of Human Resources (HR) was responsible for onboarding education, while the Director of Nursing (DON) or nursing staff handled annual education. However, there was no staff educator currently in place. Despite additional documentation being provided, the files for Staff #42, #43, #44, #46, and #47 still lacked evidence of compliance and ethics training. The Director of HR confirmed that no further training records were available for these staff members.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Required Ethics Training for a Shared Employee: The facility failed to ensure that a shared employee completed mandatory Ethics training. Record review showed no evidence of completed Ethics training in the personnel and training logs. Interviews with HR, CHR, and the Administrator confirmed that annual computerized training was monitored through reports and emails, but the employee had not completed the assigned Ethics course and the requested training policy was not provided.
Missing Required Ethics Training: The facility failed to ensure that an MA F completed mandatory Ethics training. Record review showed no evidence of Ethics training in the prior 12 months, and interviews confirmed that HR tracked completion percentages but did not specifically monitor or report delinquent staff. HR also stated there was no policy for annual Ethics training, while the DON and Administrator said staff and department heads were responsible for timely completion.
Failure to Provide Compliance and Ethics Training: The facility did not document required Compliance and Ethics training for one NA employee. Review of the personnel file showed the employee was hired in 2024 and had no training recorded within the required 1-year period, and HR confirmed the training was not provided.
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 Compliance and Ethics Training Documentation: The facility failed to ensure required compliance and ethics training was completed and documented for 3 sampled employees. A DON and 2 CNAs had missing annual training records, and one CNA had no documented initial training. The BOM confirmed the records lacked evidence of training upon hire and annually, despite the facility policy requiring it as part of orientation and on an annual basis.
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 Required Ethics Training for Shared Employee
Penalty
Summary
The facility failed to provide required Ethics training for 1 of 23 sampled staff members, PT F. Record review showed PT F had a hire date of 01/31/2025, and the facility’s training log contained no evidence that PT F completed Ethics training. Review of the training log for the previous 12 months provided by the human resources department also showed no evidence that PT F completed the required Ethics training. During interviews, the newly appointed HR D stated she was still being trained on her job duties and did not yet have access to view or run reports on annual training completion in the computerized training system. CHR E stated annual required training was computer generated quarterly, staff received emails about required and delinquent courses, and completion reports were routinely sent to department heads. CHR E also stated employees were assigned training quarterly and were responsible for completing it timely, including Ethics training, while HR and department heads were responsible for monitoring staff who did not complete training and reporting delinquent staff for disciplinary action. The Administrator stated HR was responsible for reporting staff completion of annual computerized training, that PT F was a shared employee with another sister facility that was the primary facility for assigning computerized training, and that PT F had not completed the assigned Ethics training. A requested policy addressing annual employee training was not provided prior to exit.
Missing Required Ethics Training
Penalty
Summary
The facility failed to provide required Ethics training for 1 of 23 staff reviewed for licensure and training, identified as MA F. Record review showed MA F had a rehire date of 01/02/2024, and the training log for the previous 12 months showed no evidence that MA F completed ethics training. During interview, HR G stated annual required training was computer generated quarterly, staff received recurring emails about required and delinquent courses, and completion percentages were reported during weekday stand-up meetings, but delinquent staff were not specifically reported. HR G also stated she should have monitored employees who were not completing training timely and reported delinquent staff to department heads for disciplinary action. During interviews, HR H, the DON, and the Administrator stated the HR department was responsible for reporting staff completion of annual computerized training, while department heads were responsible for ensuring staff completed assigned training. HR H stated there was no policy regarding annual Ethics training, and that ethics was included in the last quarter of the year as part of quarterly computer-generated training assignments. The DON and Administrator stated employees were responsible for completing training on time, and that delinquent staff should be held accountable, including being removed from the schedule until training was completed. A requested policy addressing annual employee training was not provided prior to exit.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide Compliance and Ethics training for one of eight staff members, nurse aide Employee E27. Review of Employee E27's personnel file showed a hire date of 6/1/24 and no Compliance and Ethics training documented between 6/1/24 and 6/1/25. During an interview on 7/18/26 at 9:50 a.m., Human Resources Employee E29 confirmed that the facility failed to provide the required training for one of eight staff members.
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 Compliance and Ethics Training Documentation
Penalty
Summary
The facility failed to ensure initial and annual compliance and ethics training was completed timely for 3 of 20 sampled employees. Employee #2, hired as the Director of Nursing on 07/29/2024, had compliance and ethics training documented on 04/01/2025, but the personnel record lacked annual training for 2026. Employee #9, hired as a CNA on 08/05/2020, had compliance and ethics training documented on 05/02/2025, but the personnel record lacked annual training for 2026. Employee #16, hired as a CNA on 04/23/2026, had no documented evidence of initial compliance and ethics training in the personnel record. On 06/29/2026 at 8:43 AM, the BOM stated there was orientation training upon hire and annual training thereafter, and that agency staff do not go directly through the facility for orientation training. The BOM confirmed the personnel records for Employees #2, #9, and #16 lacked documented evidence of compliance and ethics training completed upon hire and annually. The facility policy, Nursing Personnel Education and Training, published 11/2016, stated that education for new employees and contract staff is provided as part of orientation and scheduled annually, including Compliance and Ethics Training.
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.
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