Failure to Conduct Nurse Aide Registry Checks
Summary
The facility failed to conduct required nurse aide registry checks for adverse findings for four out of five sampled employees, which could potentially affect all 27 residents within the facility. The facility's policy, revised in April 2021, mandates conducting employee background checks, including state nurse aide registry checks for any adverse findings. However, a review of personnel files revealed that no nurse aide registry checks were completed for a cook, an LPN, and two nurse aides hired between August and October 2024. This was confirmed in an interview with the Administrator, who acknowledged the oversight in conducting these checks.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to follow its abuse-prevention hiring policy by employing an LPN who had a disqualifying domestic violence conviction. The LPN did not disclose the conviction during the hiring process, and when the criminal background check was returned, human resources staff misinterpreted a coded result as acceptable. As a result, the LPN, who should have been disqualified under the facility’s policy prohibiting employment of individuals found guilty of abuse, neglect, exploitation, misappropriation, or mistreatment, was allowed to work a scheduled shift, affecting all residents in the facility.
The facility did not complete required background checks, Nurse Aide Registry reviews, abuse registry checks, or reference checks for multiple staff members before hiring. Personnel files lacked evidence of these checks, and the background check log was incomplete. The HR Director and Administrator confirmed these omissions, and some staff had disciplinary actions or were involved in incidents without proper pre-employment screening.
A dietary aide was hired and began working without a completed BCI background check, as confirmed by review of employee files, the BCI log, and staff interview. Facility policy requires background checks to be completed before employment for all direct access staff, but this process was not followed, potentially affecting all residents.
The facility did not follow required background check procedures, resulting in the hiring of two staff members with disqualifying criminal offenses, including aggravated robbery, assault, domestic violence, and drug abuse. This failure to adhere to policy and state law was confirmed through personnel file review and staff interviews, potentially affecting all residents.
The facility did not screen new hires, including two LPNs and a Business Office Manager, against the state nurse aide registry for findings of abuse, neglect, exploitation, or misappropriation of resident property as required by policy. This lapse was confirmed through personnel file reviews and staff interviews.
The facility failed to verify three staff members against the State nurse aide registry before hiring, as required by their policy. This oversight involved a Medical Records employee, a Social Worker, and a Director of Rehabilitation, potentially affecting all 57 residents. The Human Resources representative confirmed the lapse in verification, which contradicts the facility's policy on preventing abuse, neglect, exploitation, and misappropriation.
Failure to Screen Out LPN with Disqualifying Domestic Violence Conviction
Penalty
Summary
The deficiency involves the facility’s failure to prevent employment of nursing staff with disqualifying legal convictions related to abuse, neglect, exploitation, or theft, affecting all 31 residents in the facility. Personnel file review showed that an LPN was hired on 10/28/25, and the facility’s criminal background log indicated that the LPN’s background check was submitted on 10/27/25 and returned on 11/20/25. Despite the returned background check, the LPN worked a scheduled shift on 01/06/26 from 6:53 A.M. to 7:36 P.M. The Administrator reported that the LPN had been charged and found guilty of domestic violence and had not disclosed this conviction at the time of hire. When the fingerprint/background results were returned, the acting human resources staff and the Business Office Manager/Human Resource designee recorded the Bureau of Criminal Investigation results as acceptable and did not recognize that the code “A” on the report indicated a disqualifying offense. During interview, the Business Office Manager/Human Resource designee stated she was unaware that this code disqualified the LPN from employment and, upon review of the list of employment disqualifying offenses, it was confirmed that the code corresponded to a domestic violence conviction. This was inconsistent with the facility’s written policy titled “Resident Right to Freedom from Abuse, Neglect, and Exploitation,” dated 2025, which states the facility will not employ individuals found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.
Failure to Complete Pre-Employment Background and Registry Checks for Staff
Penalty
Summary
The facility failed to conduct required background checks, Nurse Aide Registry (NAR) reviews, abuse registry checks, and reference checks for multiple employees prior to hire. Personnel files for several staff members, including CNAs, LPNs, and an activities assistant, lacked evidence of these checks. In some cases, the background check log did not include the employees, indicating that no background check was completed. The facility also failed to maintain a complete and accurate background check log, with some logs missing information for staff hired prior to certain years. Interviews with the Human Resources (HR) Director confirmed that reference checks were not completed prior to hire, and that the facility's practice was to proceed with hiring after two unsuccessful attempts to contact references. The HR Director also confirmed that there was no evidence of NAR or abuse registry checks for several employees. In one instance, a background check found in a personnel file did not belong to the employee in question. The HR Director stated that missing documentation was due to previous HR management and changes in facility ownership, resulting in lost files and incomplete records. The Administrator and Regional Director of Operations (RDO) demonstrated a lack of understanding regarding the difference between the abuse registry and the NAR, with the Administrator stating she thought they were the same. The RDO confirmed that, in the past, reference checks were considered complete after two documented attempts, regardless of whether references were actually obtained. Several employees had disciplinary actions or were involved in self-reported incidents, but there was no evidence that required pre-employment checks were completed for them. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Failure to Complete Employee Background Checks Prior to Employment
Penalty
Summary
The facility failed to ensure that employee background checks were completed prior to employment, as required by facility policy. Specifically, review of an employee file for a dietary aide revealed that the individual began employment without evidence of a completed Bureau of Criminal Investigation (BCI) background check. The BCI log did not show that a background check was performed for this employee, and the Human Resource Director confirmed that the check had not been completed. Facility policy mandates that background and criminal checks, including fingerprinting, must be initiated within two days of an employment offer and completed before the employee starts work. This lapse had the potential to affect all 56 residents in the facility.
Failure to Screen Staff for Disqualifying Offenses
Penalty
Summary
The facility failed to ensure that staff hired were free of disqualifying offenses as required by Ohio law and facility policy. During a review of personnel files, it was found that a Certified Nursing Assistant (CNA) was hired despite having a background report showing charges for aggravated robbery, aggravated assault, and domestic violence, all occurring in Ohio. Additionally, a Maintenance Supervisor was hired with a background report indicating prior charges for aggravated robbery and drug abuse. These findings were confirmed during an interview with the Human Resource Manager, who acknowledged that the disqualifying offenses were disregarded during the hiring process. The facility's policy requires background checks to be conducted in accordance with Ohio law and to verify that applicants are not excluded from federally funded programs. However, the review revealed that these procedures were not followed for two out of eleven personnel files reviewed, potentially affecting all 59 residents in the facility. The deficiency was identified during a complaint investigation and was substantiated by documentation and interviews.
Failure to Screen New Employees Against State Nurse Aide Registry
Penalty
Summary
The facility failed to ensure that new employees were screened against the state nurse aide registry for findings related to abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. This deficiency was identified through a review of personnel files, staff interviews, and facility policy, affecting three out of six personnel records reviewed. Specifically, two LPNs and a Business Office Manager were hired without being screened against the state nurse aide registry as required by facility policy. Interviews with Human Resources and the Administrator confirmed that these employees were not screened upon hire. The facility's policy mandates background checks and prohibits employment of individuals with findings of abuse, neglect, exploitation, or related disciplinary actions. At the time of the survey, all three employees were subsequently screened and no abuse concerns were found, but the initial failure to conduct the required checks constituted the deficiency.
Failure to Verify Staff Against Nurse Aide Registry
Penalty
Summary
The facility failed to ensure that staff hired did not have findings of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property entered into the State nurse aide registry. This deficiency was identified through a review of personnel files, interviews, and policy reviews. Specifically, the personnel files for three staff members, including a Medical Records employee, a Social Worker, and a Director of Rehabilitation, showed no evidence of being checked against the Nurse Aide Registry prior to their hire dates. This oversight had the potential to affect all 57 residents in the facility. During an interview, the Human Resources representative confirmed that these staff members, who had the potential to provide direct resident care, were not verified against the nurse aide registry before being hired. The facility's policy, titled 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program,' dated April 2021, mandates that staff with such findings should not be employed. The failure to adhere to this policy indicates a significant oversight in the facility's hiring practices.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
