Compliance Program and MDS Documentation Irregularities
Summary
The facility failed to implement an effective compliance and ethics program with sufficient monitoring and auditing mechanisms to detect and prevent potential violations and to ensure the integrity of data reported to CMS. The facility also failed to ensure employees could report suspected violations by a high-level leader without fear of retaliation. These failures were associated with documentation and MDS irregularities involving unsupported or inconsistently reported diagnoses for four residents reviewed: R31, R39, R40, and R61. For R31, the admission record identified an admission date of 1/25/23, but the quarterly MDS did not contain diagnosis code F33.3 in Section I. RN-A later modified the MDS to add F33.3, and the diagnosis audit report showed the diagnosis had been added to the EMR with an effective date of 1/25/25. However, a provider progress note from 4/21/26 did not include F33.3 and instead documented severe Lewy body dementia with agitation and depressive disorder in remission. The resident’s progress notes did not reflect supporting documentation for the F33.3 diagnosis, and a provider order for that diagnosis was requested but not received. For R39, the significant change in status assessment MDS completed by RN-A included F33.3, but the history and physical dated 8/13/23 identified late onset Alzheimer’s disease without behavioral disturbance and generalized anxiety disorder, not F33.3. The diagnosis audit report showed F33.3 was added to the record with an effective date of 8/17/23, and a provider order for F33.3 was requested but not received. For R40, the SCSA MDS initially did not identify F33.3, then RN-A added it through a modification and RN-B later removed it. The diagnosis audit report showed F33.3 was added to the EMR with an effective date of 1/15/25. A physician update facsimile dated 8/17/25 referenced use of F33.3 related to behaviors, agitation, and trazodone use, but the provider progress note from 3/24/26 did not include F33.3 and instead documented mild late onset Alzheimer’s dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. NP-F stated she was not aware either R40 or R39 had the diagnosis and confirmed it was not on their current or historical diagnosis lists.
Penalty
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Failure to maintain an effective compliance and ethics program: residents and staff reported the DON yelled at employees, discussed residents inappropriately, and created fear of retaliation, while staff described underreporting, altered statements, and instructions to cover up incidents. Several employees were unfamiliar with the compliance hotline or unsure how to use it, and the NHA acknowledged staff concerns but did not report them to corporate leadership.
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.
Inaccurate medication administration documentation was found for two residents. One resident’s nebulizer treatment was documented as given even though an LPN said it was not administered because the resident was in activities. Another resident’s eye ointment was documented as administered on the EMAR, but an LPN stated the medication never arrived at the facility and the charting was inaccurate. The DON stated nurses were expected to document accurately and not falsely document in the medical record.
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
Penalty
Summary
The facility failed to effectively implement its compliance and ethics program by not promoting ethical conduct related to reporting resident incidents and allegations of abuse, not providing effective oversight by high-level personnel to ensure adherence to ethical standards, and not maintaining effective lines of communication that encouraged staff and residents to report concerns without fear of retaliation. During interviews, residents stated the DON yelled at staff, discussed other residents in front of residents and visitors, and that some residents feared retaliation and therefore did not report concerns. One resident also reported that staff were disrespectful toward Spanish-speaking residents. Staff interviews reflected similar concerns. An LPN stated management changed staff statements, claimed they were unaware of reported incidents, and that the facility was underreporting incidents. The LPN said the DON instructed staff what to write to cover up incidents, that medications were documented as administered when they were not available, and that staff were required to contact the DON before initiating CPR, which could delay care. An RN stated the DON insulted her, made comments about Hispanics, screamed and yelled at staff, and that residents had videotaped the DON yelling at her. A CNA stated she was unaware of the ethics and compliance hotline and believed concerns should be reported to HR, while another CNA stated she feared losing her job if she reported concerns and had instead gone to Social Services when residents voiced concerns. The NHA acknowledged staff had expressed concerns about the DON's harsh and rough interactions with staff, but said she addressed them directly with the DON and acted as a mediator; she had not reported those concerns to corporate leadership. The NHA stated staff received ethics and compliance education upon hire and annually and could report concerns to her or the corporate hotline, but she was unaware that staff or residents feared retaliation. The Corporate Compliance Officer stated the hotline accepted anonymous and identified reports, concerns could also be submitted by QR code, and employees received annual ethics and compliance training, but the report also showed staff were unfamiliar with the hotline and the facility's ethics and compliance program. The facility's compliance poster and policies stated employees were expected to report illegal or unethical issues and that the program included open lines of communication and reporting suspected ethical misconduct.
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.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation related to medication administration for two residents. One resident, admitted with diagnoses including metabolic encephalopathy, asthma, chronic respiratory failure with hypoxia, and COPD, had an EMAR entry showing Ipratropium-Albuterol nebulizer treatment documented as administered at 1500, but an LPN later stated she did not give the treatment because the resident was in activities. This created a discrepancy between the medication record and the nurse’s account of what occurred. A second resident, admitted with diagnoses including Parkinson’s disease, type 2 diabetes mellitus with hyperglycemia, vascular dementia, and anxiety, had an order for Bacitracin ophthalmic ointment for a sty in the left eye. The EMAR showed the medication as administered on multiple dates, but administration notes stated the medication was on order or awaiting pharmacy delivery. During interview, an LPN stated the medication never arrived at the facility and that documentation showing it was given was inaccurate. The DON stated nurses were expected to document according to policy and not falsely document in the medical record, and the facility stated it did not have a documentation policy for this citation.
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.
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