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
Below are regulatory guidelines relevant to this citation:
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.
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.
Failure to provide Compliance and Ethics training to five of five direct care staff members, including an LPN, three NAs, and an RN. The NHA stated that education is tracked by calendar year and that no 2025 education records could be found for the reviewed employees, and the HR Director confirmed the training was not provided.
Missing Compliance and Ethics Training for Direct Care Staff: The facility could not provide evidence that 5 CNAs had received required compliance and ethics training, even though each had worked there for more than 1 year. The facility's policy required this training and documentation in personnel files, but the HR Director, NHA, and Director of Operations confirmed there was no organized training record system, no Nurse Educator or Staff Development Coordinator, and no evidence the training had been provided.
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.
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.
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.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
Compliance and Ethics training was not provided to five of five direct care facility staff reviewed, including an LPN, three NAs, and an RN. During interviews, the NHA stated that staff education is tracked by calendar year from January through December, and that the State Agency requested employee education records for the identified staff. The NHA later stated that the facility was unable to find any education records for those employees for the year 2025. The HR Director then confirmed that the facility failed to provide Compliance and Ethics training to the five direct care staff members reviewed.
Missing Compliance and Ethics Training for Direct Care Staff
Penalty
Summary
The facility did not ensure that 5 of 5 direct care staff reviewed received the required training regarding compliance and ethics. The CNA staff reviewed were TT, UU, VV, WW, and XX, all of whom had worked at the facility for longer than 1 year. The facility's policy, last revised 1/1/25, states that training content includes written standards, policies, and procedures for the facility's compliance and ethics program, and that documentation of required training will be forwarded to HR for placement in the personnel file. On 5/4/26, the surveyor selected the five CNAs from a list of employees provided by the facility and reviewed their annual performance reviews and required training. The facility was unable to provide evidence that any of the five CNAs had received compliance and ethics training. During interviews, the HR Director stated that annual training was tracked by nursing and that there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed there was no evidence of compliance and ethics training being provided and stated that training records were in boxes kept by the previous DON, with no organized system or designated staff member maintaining training schedules or documentation.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.