Failure to Conduct Timely and Thorough Staff Background Checks
Summary
The facility failed to ensure that staff background checks were completed thoroughly and timely for three out of eight staff members reviewed. Specifically, the background information disclosure (BID) checks for a Medication Technician and two Certified Nursing Assistants (CNAs) were not conducted as required. The Medication Technician's BID had not been updated since the initial check in December 2019, and the CNA's BID had not been updated since November 2019, lacking the necessary Wisconsin results. Additionally, the BID for another CNA was incomplete, with no questions answered on the document. The facility's policies and procedures require that background checks, including re-checks, be conducted every four years and include specific documentation such as a Department of Justice response letter and governmental findings report. However, these requirements were not met for the staff members in question. Interviews with the Human Resources representative and the Nursing Home Administrator confirmed that background checks should be completed every four years and include all necessary documentation, but this was not adhered to in these cases.
Penalty
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The facility failed to complete abuse registry checks upon hire for seven of seven newly hired employees reviewed, including the Administrator, DON, BOM/HR, Activities Director, an LPN, and two Med Techs. Personnel records showed no individual abuse registry checks were maintained, and the BOM/HR and Administrator confirmed the facility was not completing Office of Inspector General abuse registry checks for newly hired staff.
The facility failed to properly screen and document clearance for a NA with disqualifying criminal history information before hire, as required by its abuse, neglect, and exploitation policy. A BCI check showed disqualifying information, yet the NA was hired, completed orientation, and worked independently based only on verbal disclosure of an old drug-related charge, without written details or verification. Later, a staff member reported witnessing this NA grab a resident’s face and kiss the resident on the lips, and a community complaint alleged inappropriate interactions with the same resident, prompting involvement of local police.
Facility staff failed to complete required pre-employment screening, resulting in multiple employee files lacking sworn statements, state police criminal background checks, or verification of licenses/certifications. An internal audit had already identified missing documents, but no corrective action was taken and the issue was not brought to QA. One employee was hired and allowed to work before the criminal background report was obtained and reviewed; when the report was later received from a sister facility, it showed barrier crimes including assault of a family member, malicious wounding, and indecent exposure. The Regional HR Director reported prior problems with the state police online system and reliance on another facility’s HR staff to obtain background checks, and leadership offered no additional information during interviews.
Failure to check nurse aide registry before hiring staff. The facility did not verify newly hired employees on the nurse aide registry before they began working with residents. An LPN file showed no registry search before employment, and the HRM stated he did not perform these checks for applicants. The Administrator confirmed this had not been done for non-CNA staff hired since the HRM started, including RNs, LPNs, ADON, dietary, housekeeping, maintenance, and administrative staff.
The facility employed a cook who had a prior felony conviction for aggravated assault with a deadly weapon, despite state law barring such individuals from employment and the facility’s own abuse/neglect policy prohibiting hiring persons found guilty of abuse, neglect, exploitation, misappropriation, or mistreatment. The cook’s personnel file showed multiple criminal history checks, and the cook reported serving four years in jail for the offense. The HR Director reviewed the criminal history and identified both a deferred adjudication and a subsequent conviction with a four-year confinement term, concluding this created a lifetime employment bar. The DON stated the HR Director was responsible for criminal history checks and the Administrator for oversight of that process, while the Administrator maintained his belief that the cook remained eligible for employment based on his interpretation of the criminal history and deferred adjudication.
Failure to Check Nurse-Aide Registry for Ancillary Hires: The facility did not check the Nurse Aide registry when two ancillary employees were first hired. No documentation was available for a Maintenance Tech and a Housekeeper, and the HR Generalist stated the facility does not check the registry for ancillary staff. The deficiency was verified by the HR Generalist, the Clinical Manager, and Administrative staff.
Failure to Complete Abuse Registry Checks for Newly Hired Staff
Penalty
Summary
The facility failed to ensure newly hired employees were screened through the abuse registry upon hire to identify potential findings related to abuse, neglect, exploitation, or misappropriation of property for seven of seven newly hired employees reviewed. Personnel file review showed no abuse registry check completed upon hire for the Administrator, DON, Business Office Manager/Human Resources #500, Activities Director #248, LPN #258, Med Tech #238, and Med Tech #266. The facility census was 55, and the deficiency was identified based on personnel file review, staff interview, and facility policy. During interview, the Business Office Manager/Human Resources #500 stated the facility was not completing abuse registry checks for employees hired at the facility. The Administrator stated corporate staff provided monthly Microsoft Excel reports indicating no Office of Inspector General matches were identified, but the facility did not maintain individual abuse registry checks for newly hired employees and only kept a filled-out Excel sheet. The Administrator later confirmed the facility had not been completing Office of Inspector General abuse registry checks for newly hired staff to ensure there were no previous abuse concerns prior to employment.
Failure to Properly Screen and Clear NA with Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure that a prospective employee was properly screened and cleared for a history of abuse, neglect, exploitation, or misappropriation of resident property before hire. A nursing assistant, identified as Staff A, was hired on 11/18/2025 and was working independently as a NA. Prior to hire, a Bureau of Criminal Identification (BCI) check dated 11/6/2025 showed that Staff A had disqualifying information under federal and state law. Surveyor review after discovery of the positive BCI revealed that Staff A had an extensive criminal history. Despite this, the facility proceeded with the hire and allowed Staff A to complete orientation and work independently without obtaining or maintaining documentation specifying the nature of the disqualifying information, contrary to the facility’s Abuse, Neglect and Exploitation Policy, which requires screening and documentation of proof that such screening occurred. Subsequently, a facility-reported incident submitted on 4/17/2026 documented that a staff member reported witnessing Staff A grab a resident’s face and kiss the resident on the lips. A community-reported complaint submitted on 4/22/2026 alleged inappropriate interactions between the same NA and the same resident, and included a local police incident report indicating the resident’s family intended to pursue charges related to the incident. During interviews, the Human Resource Director stated that Staff A had disclosed disqualifying information related to a prior drug-related charge from about ten years earlier, but acknowledged there was no documentation specifying the nature of the disqualifying information and that this was known only by word of mouth. The Administrator stated she was aware that the BCI contained disqualifying information and that she exercised her own judgment in proceeding with the hire, and further acknowledged she did not receive documentation detailing the disqualifying information until it was brought to her attention by the surveyor.
Failure to Complete Pre-Employment Background Checks and Credential Verification
Penalty
Summary
Facility staff failed to thoroughly investigate prospective employees' histories before hiring, resulting in incomplete personnel files and delayed identification of disqualifying criminal backgrounds. A review of 25 employee records hired over the last 2 years on 4/22/26 showed that 11 files were missing at least one required document: a sworn statement, a state police criminal background search, or verification of a certificate or license. The Human Resources (HR) Director reported that an in-house audit had already identified missing documents in employee records, but no action had been taken to correct the problem or to refer the issue to the Quality Assurance committee. The HR Director further stated that an employee hired on 4/7/26 began employment before the facility received and reviewed the state police criminal background report. The background check was requested on 4/8/26, and the report was not received until the evening of 4/21/26 from a sister facility, at which time it was discovered that the employee had barrier crimes, including assault of a family member, malicious wounding, and indecent exposure. The employee was terminated on 4/22/26 before clocking in that day. The Regional HR Director explained that the facility’s process was to obtain background checks and ensure all required documents were completed, and stated that it was their policy not to hire employees with past criminal prosecutions. She also reported that the in-house HR Director had experienced issues with the state police online system and had relied on a sister facility’s HR Director to obtain the documents. During subsequent interviews with the Administrator, Assistant Administrator, Regional President of Operations, DON, Regional Nurse Consultant, and Regional MDS Consultant, no additional information was provided and staff voiced no comments.
Failure to Check Nurse Aide Registry Before Hiring Staff
Penalty
Summary
The facility failed to ensure newly hired staff were checked on the nurse aide registry to verify eligibility for employment before working with residents. Review of the personnel file for an LPN showed a hire date of 02/18/26, but there was no evidence that the LPN had been searched on the nurse aide registry before beginning work in the facility. The census was 52 residents, and the deficiency was identified through review of personnel files, staff interviews, and policy review. During interview, the HRM stated he did not perform nurse aide registry searches for applicants prior to hiring and believed the registry was checked through the corporation's comprehensive background check. The Administrator confirmed that the HRM had not completed nurse aide registry searches for staff, except CNAs, hired since he began the position on 10/06/25. The Administrator also provided a list of 22 non-CNA staff hired during that period, including ADON, RNs, LPNs, maintenance, activities, dietary, housekeeping, and administrative staff. The facility later completed nurse aide registry searches for those 22 employees, and the review showed no findings of abuse, neglect, or misappropriation. The facility policy stated that nurse aide registry checks were to be completed prior to hiring all potential new employees, licensed and unlicensed, and new volunteers.
Employment of Staff Member With Disqualifying Aggravated Assault Conviction
Penalty
Summary
The deficiency involves the facility’s failure to prevent the employment of an individual with a disqualifying criminal conviction for aggravated assault with a deadly weapon. The employee, referred to as Cook A, was hired with a documented hire date of 11/04/24 and worked in the facility until 04/24/26. Her personnel file showed that criminal history checks were conducted on three occasions: at hire and on two later dates. During interviews, Cook A stated she had been convicted of aggravated assault with a deadly weapon in the late 1990s, served four years in jail from 1998 to 2002, and was released in 2002. The HR Director reported that she had pulled and reviewed Cook A’s criminal history and stated that, based on the report, Cook A would not be eligible for hire if she applied at the time of the survey because she had a felony from 1996. The HR Director later reviewed the criminal history in detail, noting an arrest for aggravated assault with a deadly weapon under Texas Penal Code 22.02(a)(2), classified as a second-degree felony. The record showed an initial court disposition of deferred adjudication, followed by another court entry reflecting a conviction for aggravated assault with a deadly weapon, a four-year term of confinement, and a sentence expiration date in 2002. The HR Director concluded that this constituted a lifetime bar to employment. Other facility staff provided information about the hiring and background check process. The Dietary Manager stated that the HR Director and Administrator review background checks and inform department heads whether an applicant is acceptable for hire, and that the prior HR Director had indicated Cook A was acceptable. The DON stated that the HR Director was responsible for ensuring criminal history checks on new hires and annually, and that the Administrator was responsible for ensuring the HR Director reviewed criminal history correctly. The Administrator stated his belief that Cook A was eligible for hire and that his understanding of her criminal history was that she was convicted, served time, and then likely received deferred adjudication. The report cites the Texas Health and Safety Code, Chapter 250.006, which bars employment of persons convicted of aggravated assault under Penal Code 22.02, and the facility’s own abuse/neglect policy, which prohibits employing individuals found guilty of abuse, neglect, exploitation, misappropriation, or mistreatment by a court of law.
Failure to Check Nurse-Aide Registry for Ancillary Hires
Penalty
Summary
The facility failed to check the nurse-aide registry when ancillary staff were first hired, as required, for 2 of 2 ancillary employees reviewed. On 04/14/2026 at approximately 1:10 p.m., there was no documentation readily available showing that Maintenance Tech #45 and Housekeeper #46 had been checked on the Nurse Aide registry. During an interview at approximately 1:13 p.m., the HR Generalist and Educator stated that the facility does not check the Nurse Aide registry for ancillary staff, including Maintenance Tech #45 and Housekeeper #46. The deficiency was verified with the HR Generalist and Educator and the unit Clinical Manager, and it was acknowledged by the unit's Administrative staff during the exit interview on 04/15/2026 at approximately 2:30 p.m.
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