Failure to Ensure Annual Compliance and Ethics Training for Staff
Penalty
No penalty information released
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
The facility failed to ensure that annual Compliance and Ethics training was completed for one of eleven employees reviewed, specifically a registered nurse hired in July 2021. Record review showed that this staff member had not received the required annual training on compliance and ethics for the period from July 2024 through July 2025. Interviews with facility leadership confirmed that all staff were expected to complete mandatory training annually, as outlined in the facility's policy, which requires participation in both initial orientation and annual in-service training, including compliance and ethics program standards. The deficiency was identified through both record review and staff interviews.