Lack of Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to provide compliance and ethics training to its staff, as evidenced by the absence of documentation verifying such training. During the survey, the administrator was unable to produce any records of compliance or ethics in-services for staff in the provided in-service binders for 2024 and 2025. Further searches by facility leadership, including the nurse consultant and assistant director of nursing, did not yield any additional documentation. The administrator confirmed that there was no further documentation available regarding compliance or ethics training. Additionally, the facility assessment did not identify a need for compliance and ethics training, and the job description for certified nursing assistants only referenced involvement in yearly mandated education without specifying compliance or ethics. Although the facility has a compliance and ethics program and a hotline for reporting concerns, there was no evidence that staff had received training on these topics. This deficiency has the potential to affect all 93 residents residing in the facility.