Failure to Maintain Effective Compliance Program and Non-Retaliatory Reporting Culture
Summary
The deficiency involves the facility’s failure to develop, implement, and maintain an effective compliance and ethics program that promotes quality of care and prevents and detects violations. Facility policies such as the Code of Conduct and the Non-retaliation and Non-retribution policy state that all affected individuals must act ethically, report concerns in good faith, and are protected from retaliation when reporting suspected violations, fraud, waste, abuse, or unethical behavior. The Non-retaliation policy describes prohibited retaliatory actions and lists various reporting channels, including an anonymous hotline, and the abuse prevention policy states that all employees shall receive information on how and to whom they report concerns without fear of retribution. Despite these written policies, staff interviews revealed that employees did not believe they could report compliance concerns without retaliation and did not trust the facility’s reporting mechanisms. One staff member stated that reporting violations to the DON was a “long shot” and that a unit manager conveyed that their title was more important than the staff reporting to them. Another staff member reported fear of losing vacation, overtime, or future work if they reported issues, and described being contacted by the DON after a prior State Surveyor interview to ask what was discussed. Additional staff reported that anonymous reporting was “a joke,” that someone would always find out who reported, and that they did not feel confident reporting beyond their immediate manager. Another staff member reported fear of retaliation from coworkers, including threats of tire slashing and physical harm, and hearing a threat in the breakroom about having a grown son beat someone up. Surveyor observations of facility administration during the survey further demonstrated an environment inconsistent with an effective compliance and ethics program. The DON told surveyors that their presence stressed staff and that they would “hate for the facility staff to get punchy” with them. During a meeting with the administrator, assistant administrator, and DON, all three spoke in elevated voices, leaned forward, clenched their fists on the table, and repeatedly challenged the survey process, the basis for the Immediate Jeopardy determination, and the questions asked of staff. They demanded to know who decided on the Immediate Jeopardy and what data were provided to supervisors. Later, when surveyors attempted to leave the building, the administrator followed them, stated they could not leave after issuing an Immediate Jeopardy, and questioned how they could depart, despite the surveyors explaining the next steps. These actions and staff reports showed that the facility did not create and promote a credible, safe program contact and anonymous reporting method free from fear of retribution, as required by its own policies and regulatory standards.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Compliance Program Failed to Promote Honest Documentation and Ethical Recordkeeping: Survey findings showed a manipulated census that obscured a mixed-gender room arrangement between two residents, incomplete transfer and room-change documentation for a resident returning from the hospital, and DON-directed editing of e-records. LNs and IDT members stated the DON routinely left records unlocked to edit change-of-condition documentation, add notes, and make it appear team members were present when records were created.
The facility failed to enforce its compliance and ethics program when an Administrator allowed a Dietary Manager to work with vulnerable residents before a background check was completed. Although policy required criminal screening before hire and before unsupervised resident contact, the staff member was working while the BGI remained pending. The HRD stated this was not the normal process, and the DON and DCO said staff should not work with vulnerable residents until screening was complete.
Compliance and Ethics Program Not Effectively Implemented: The NHA was not aware she was the designated Compliance Liaison and did not recall training on the facility’s Ethics and Compliance program. She was unfamiliar with the procedures, was not aware of any reported violations, and had not been involved in written standards, staff education, internal monitoring, enforcement of disciplinary guidelines, or communication with staff regarding the compliance hotline and reporting process.
A dietary aide reported witnessing a staff member verbally and physically mistreat a resident in a wheelchair and then experienced ongoing harassment and retaliatory behavior from nursing and kitchen staff, including threatening comments, refusal to sign meal-tray forms, and aggressive, profane interactions. The aide, described by a coworker as quiet and respectful, ultimately resigned by phone, citing fear for personal safety and difficulty identifying harassing staff because they were not wearing name badges. Leadership, including the Administrator, DON, Risk Manager, Unit Manager, and HR Director, acknowledged awareness of harassment concerns but did not conduct an investigation into the reported retaliation, despite a written policy requiring protection of individuals who report suspected abuse.
Failure to maintain an effective Compliance and Ethics Program led to staff electronically signing residents’ names on binding arbitration and admission documents. Three residents with legal guardians and who were not able to make informed decisions had arbitration agreements and other consents signed in their names through the EMR, and the AD confirmed the residents did not actually sign the forms. The Administrator reported there was no compliance binder in the office or breakroom, no audits, and no staff education, despite the facility policy describing a formal compliance structure with a Compliance Officer, Compliance Liaison, committee, training, and documentation.
Staff provided inconsistent and misleading statements about a resident's death, with conflicting documentation and witness accounts regarding care and the initiation of CPR. High-level personnel failed to ensure truthful reporting, and staff reported being pressured to provide false statements. Allegations of neglect and ethical violations were not reported to authorities, and the facility did not foster effective communication or protect staff from retaliation, resulting in an inadequate investigation of the resident's death.
Compliance Program Failed to Promote Honest Documentation and Ethical Recordkeeping
Penalty
Summary
The facility failed to maintain its compliance and ethics program when it did not promote honest and ethical behavior in work-related activities. Survey findings identified false medical records and reports, including a manipulated resident census that obscured an overnight mixed-gender room arrangement between a male resident and a female resident. The census showed the male resident transferred to the hospital on 6/2/26 and the female resident admitted that evening, then showed the male resident returning at 3:20 a.m. on 6/3/26 and being placed in a bed while the female resident’s bed was listed as vacant after she was moved later in the day. Progress notes documented that curtains were drawn for privacy, and staff interviews confirmed both residents occupied the same room during the evening and overnight shifts until they were relocated during the day. Record review also found incomplete documentation related to the male resident’s transfer and room changes. The registered nurse supervisor stated that charge nurses were expected to complete the written 7-day bed hold notice during hospital transfers, but no bed hold notice was found for the resident. The supervisor was also unable to produce a room change notification for the resident’s return from the hospital on 6/3/26, and only a later room change notification dated 6/4/26 was available after a second room relocation occurred. Additional interviews and record review showed that the Director of Nursing instructed licensed nurses to leave electronic records saved but unlocked so the DON could edit them and complete resident change-of-condition documentation according to the DON’s standards. Licensed nurses confirmed this practice, and interdisciplinary team members stated the DON routinely edited change-of-condition records, entered notes and recommendations, and added the names of team members so it appeared they were present when the records were created. The administrator stated there was no documentation of the resident’s room changes on 6/3/26 and that the mixed room arrangement was not normal practice, while the DON stated the multiple room changes from 6/2/26 to 6/4/26 were necessary to meet resident and facility needs.
Failure to Enforce Background Check and Compliance Procedures
Penalty
Summary
The facility failed to implement, maintain, and enforce an effective compliance and ethics program with monitoring and auditing systems related to abuse screening and hiring practices. The report states that the facility’s policies required criminal background checks for all employees before hire and prohibited staff from working with vulnerable residents until screening was completed, but these procedures were not followed for a Dietary Manager who was hired while the background inquiry was still pending. Record review showed the Dietary Manager’s background inquiry was submitted before hire but had not been completed. During interviews, the Dietary Manager stated the Administrator knew the background check was still in process and approved them to work anyway. The Administrator confirmed the staff member was working in the facility without a current completed background check and stated they trusted the staff member and did not think supervision was necessary while the check was pending. The Human Resources Director stated the normal process was to complete the background check before a new staff member worked unsupervised with vulnerable residents, and that this was not the normal process in this case. The Human Resources Director also stated the Administrator made the decision to let the staff member work without the completed background check. The DON and Director of Clinical Operations stated new staff should not work with vulnerable residents until the background check was completed and were not aware the Administrator had approved the staff member to work unsupervised while the background inquiry remained pending.
Compliance and Ethics Program Not Effectively Implemented
Penalty
Summary
The facility failed to implement policies and procedures to ensure an effective Compliance and Ethics program. During an interview, the Regional Nurse stated that the parent organization had a corporate director of compliance and that staff could report suspected violations to a hotline. The Nursing Home Administrator stated she did not recall having training on the facility Ethics and Compliance program, thought online training was scheduled yearly, and believed postings for the hotline were in common areas. She identified possible reportable issues as HIPAA/privacy concerns, resident care concerns, and staffing concerns, but said she was not aware of any reported violations and had not responded to any alleged violations. The Nursing Home Administrator was not aware of who the facility Compliance liaison was and was not familiar with the procedures, stating she would review the policy and find out. A policy provided to surveyors was dated 11/01/2019, while a later policy dated 12/09/2024 stated the facility had a Corporate Compliance and Ethics Program, designated a compliance contact, and described reporting methods, audits, and the administrator’s responsibility for maintaining compliance documentation. In an email after the interview, the Nursing Home Administrator confirmed she was the Compliance Liaison, but prior to that she had not been aware she was designated in that role and therefore was not involved with written standards, training, internal monitoring, enforcement of disciplinary guidelines, communication with staff, or participation in a compliance committee.
Failure to Protect Abuse Reporter From Retaliation and Harassment
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse-prevention and anti-retaliation policies to protect an employee who reported alleged abuse of a resident. A dietary aide (Staff Q) reported witnessing a staff member pull Resident #4 by the wheelchair arm and tell the resident, “get your ugly *** out here,” and he immediately reported this to a Unit Manager, who then notified the Risk Manager. After making this report, Staff Q stated that staff spoke loudly about him in a threatening manner, made retaliatory remarks, refused to sign meal-tray forms, and used aggressive tones and profanity toward him. He reported ongoing harassment from both kitchen and nursing staff, but had difficulty identifying those involved because staff were not wearing name badges. Staff Q ultimately resigned by phone, stating he feared for his safety and reiterating that he could not positively identify all involved staff due to the lack of visible name badges. Multiple interviews with facility leadership and staff showed that no investigation into the reported harassment and retaliation was conducted, despite the facility’s written policy stating that the administrator ensures the person reporting suspected violations is protected from retaliation or reprisal. The Dietary Manager reported that when Staff Q told her he was resigning due to harassment after reporting abuse, she did not investigate the harassment herself but notified the Administrator and Risk Manager. The 3rd Floor Unit Manager acknowledged hearing that Staff Q resigned due to harassment but stated staff-to-staff harassment was outside her scope and should be handled by HR. The Risk Manager stated she attempted to contact Staff Q twice, was unable to reach him, and then unsubstantiated the abuse allegation without further investigation. The Administrator confirmed awareness that Staff Q reported being harassed but acknowledged that no investigation into the harassment occurred. A former dietary staff member (Staff R) also reported experiencing harassment from nursing and kitchen staff during his employment and stated he had reported it to HR, who told him to speak with his supervisor, who was allegedly involved in the harassment. The HR Director recalled a harassment report from Staff R, acknowledged uncertainty about the timeline, and admitted staff were “bad about wearing badges,” despite repeatedly instructing them to wear them.
Failure to Maintain an Effective Compliance and Ethics Program
Penalty
Summary
The facility failed to maintain and implement an effective and operational Compliance and Ethics Program. During record review and interviews, the facility’s policy described a compliance structure that included a Compliance Officer, a Compliance Committee, the Administrator as the onsite Compliance Liaison, regular staff education, audits, and a binder of compliance documentation in the Administrator’s office and breakroom. However, when the Administrator was interviewed, she reported that she did not have the binder in her office or the breakroom, did not conduct audits, and did not provide any education. Three residents, R3, R6, and R88, were reviewed in relation to binding arbitration and admission documents. Each of these residents had legal guardians and were deemed incompetent to make informed decisions for themselves. Their arbitration agreements were electronically signed with the residents’ names, and additional admission documents also contained electronic signatures in the residents’ names, including a Consent to Medical Care and Treatment form for R3 and financial and medical consents and documents for R6. The Admissions Director stated that when the signature section was clicked in the EMR, it automatically electronically signed the forms with the residents’ names, and confirmed that R3, R6, and R88 did not actually sign the forms themselves. The Administrator was unaware that residents with legal guardians who could not make their own decisions had their names electronically signed by staff on legally binding agreements and stated staff should never sign a resident’s name on any agreement or contract. The Corporate Compliance and Security Officer reported she was revising and updating compliance policies and that the Administrator would have additional information about facility-specific education, audits, and compliance documentation, but no additional documents were provided before the end of the survey.
Failure to Ensure Ethical Practices and Accurate Reporting in Resident Death
Penalty
Summary
The facility failed to ensure staff adhered to ethical practices and professional standards, resulting in inconsistent and misleading statements regarding the circumstances of a resident's death. Staff provided conflicting accounts about the last time the resident was observed, the care provided, and the initiation of CPR. Documentation in the resident's medical record did not align with staff witness statements, and there were discrepancies in the reported times and actions taken during the code event. For example, one LPN documented that the resident was alert and oriented at a time when she later stated she had not assessed the resident, and a CNA's documentation conflicted with her statements about providing care. Further, high-level personnel oversight was lacking, as evidenced by the failure of the DON and Administrator to ensure accurate and truthful reporting. Staff reported being instructed to provide false witness statements under threat of job loss, and there was evidence that the crash cart was placed in the resident's room prior to EMS arrival to give the impression that CPR was in progress. The DON and Administrator denied knowledge of the resident being deceased prior to CPR and failed to report allegations of neglect and ethical violations when they were brought to their attention by staff. The facility also failed to develop effective lines of communication to encourage immediate reporting of violations without fear of retaliation. When a staff member reported allegations of neglect and unethical behavior, these concerns were not reported to the appropriate authorities. The compliance officer confirmed that ethical behavior was expected, but the facility's actions did not support an environment where staff could report violations without fear. These failures contributed to an inadequate investigation into the resident's death and undermined the facility's compliance and ethics program.
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