Failure to Provide Mandatory Annual Compliance and Ethics Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received mandatory annual Compliance and Ethics training, as evidenced by the education record of one employee. During a complaint survey, surveyors reviewed education records for five randomly selected employees for the period from January 2025 through February 2026. For Staff #20, who was hired on 7/31/24, there was no documentation showing completion of Compliance and Ethics training during that review period. In an interview on 2/9/26 at 2:13 PM, the Administrator confirmed there was no evidence that this staff member had received the required annual Compliance and Ethics training. This deficiency was identified for 1 of 5 employees whose records were reviewed for compliance with the facility’s mandatory Compliance and Ethics education requirements.
