Based on interview and record review the facility failed to ensure the operating organization for each facility included compliance and ethics program annual training if the operating organization operated five or more facilities for 14 of 14 employees (Administrator, DON, ADON, LVN A, LVN C, LVN D, AD, DM, DOR, CNA E, CNA F, CNA G, CNA H and CNA K) reviewed for training in that: The facility failed to ensure annual compliance and ethics training was provided to the Administrator, DON, ADON, LVN A, LVN C, LVN D, AD, DM, DOR, CNA E, CNA F, CNA G, CNA G, CNA H and CNA K. This failure could place them at risk of poor care or victimization.Findings include: Record review of the personnel file for the Administrator indicated she was hired at the facility on 8/10/2026. …
F946
Administration Deficiencies
Provide training in compliance and ethics.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F946 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F946 finding.
The harm level
How severely F946 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D5432.1% | E5834.5% | F4023.8% |
| No harm, potential for minimal | A— | B106.0% | C63.6% |
In the surveyor’s words
What an F946 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for one of five employees (Physical Therapist (PT) Employee E12). Findings include: Review of facility policy Facility Assessment last reviewed 8/4/26, with a previous review date of 1/14/26, indicated compliance with the annual trainings includes post tests to determine competency and designated Managers/ Supervisors monitor attendance. The mandatory training program included Corporate Compliance and Ethics. Review of PT Employee E12's personnel record indicated a hire date of 4/23/18. …
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