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F0658
E

Falsification of Staff Education Records

Montrose, Michigan Survey Completed on 06-11-2025

Penalty

Fine: $46,6202 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that the facility falsified documentation regarding the completion of required online education for staff, potentially affecting all 112 residents. Multiple staff members, including nurses and certified nursing assistants (CNAs), reported during interviews that they had not completed the mandatory online education modules due to issues such as lack of access, inability to log in, or not receiving login credentials. Despite these statements, facility records indicated that these staff members had completed most or all of the required education modules on the same day. Further investigation revealed that the Staff Development Nurse (SDN) acknowledged possible errors in recording education completion, including the possibility that education modules were marked as completed for staff who had not actually participated. The SDN was unable to verify when or if staff had accessed the education program and admitted to entering education completion for others during orientation, which may have resulted in inaccurate records. One CNA, upon logging into the system for the first time, found all modules marked as completed despite never having accessed the program before. The Director of Nursing (DON) and SDN were questioned about who had access to the education system and how the documentation was completed, but could not provide a clear explanation. A review of facility policy confirmed the requirement for staff to demonstrate competency through education. The falsification of education records meant that staff may not have received necessary training in areas such as infection control, emergency preparedness, and resident rights, as required by facility policy.

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