Failure to Conduct Timely Background Checks
Summary
The facility failed to ensure that it did not employ individuals with findings of abuse, neglect, exploitation, or mistreatment by not conducting timely and complete background checks for several staff members. Specifically, four staff members, including a Registered Nurse (RN D), a Certified Nursing Assistant (CNA E), a Medication Technician (MT C), and a Housekeeper (HK F), did not have background checks completed every four years as required. The facility's policy required background checks at the time of hire and every four years thereafter, but this was not adhered to, leading to a deficiency in compliance with the Wisconsin Caregiver Program regulations. The deficiency was further evidenced by the case of HK F, who disclosed a conviction of disorderly conduct on their Background Information Disclosure (BID) form. Despite this disclosure, the facility failed to obtain the necessary criminal complaint and judgment of conviction documents as required by the Wisconsin Caregiver Program guidelines. The BID form indicated multiple charges and convictions for disorderly conduct within the past five years, yet the facility did not have any documentation to support this information. During interviews with the Nursing Home Administrator (NHA), it was revealed that there was confusion regarding the facility's policy on background checks. The NHA initially believed that background checks were performed according to policy but later confirmed that they were not conducted every four years as required. This oversight resulted in the facility employing individuals without the necessary background checks, thereby failing to comply with state regulations designed to protect residents from potential abuse or neglect.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not complete a required Georgia Criminal History Check System (GCHEXS) fingerprint background check for a CNA, as identified during review of ten employee files with a census of eighty residents. The facility’s abuse-prevention policy required criminal background checks for all employment candidates, but there was no documentation of a fingerprint records check for this CNA. The HR manager, who is responsible for background and fingerprint checks and maintaining employee files, confirmed that the GCHEXS fingerprint check had not been conducted, resulting in a deficiency under F-Tag 600.
The facility did not follow its own policy requiring pre-employment screening, including criminal background checks and Adult/Child Central Registry checks, for all new staff before they worked with residents. Record review showed that a NA was hired without a criminal background check, and a dietary staff member was hired without a criminal background check or Adult/Child Central Registry check. The BOM confirmed that these checks were required for all new employees but were not completed for these two staff members.
The facility did not follow its own Criminal Record/FBI Check Policy when hiring a staff member who had not been a state resident for the required two-year period. Policy required an FBI national criminal background check for such individuals upon hire, but review of the employee’s personnel file showed no evidence that an FBI check was initiated or completed. The NHA confirmed that the employee did not meet the two-year residency requirement and that the FBI check had not been done, resulting in a failure to properly screen the individual for findings of abuse, neglect, exploitation, or theft before employment.
The facility did not follow its Background Investigations policy when an LVN was hired and allowed to work without a completed reference check in the employee file. During review, the Administrator confirmed that the reference check should have been completed before the LVN began working, as the policy requires job reference checks, drug screenings, licensure verifications, and criminal conviction record checks for all applicants. This lapse was identified as having the potential to expose residents to abuse, neglect, and mistreatment.
The facility failed to follow its abuse prevention policy by hiring and retaining a CNA who had a documented finding of patient abuse on the state nurse aide registry and was listed on OIG/medical exclusion and State Board lists, without obtaining required reference checks or making reasonable efforts to uncover past criminal prosecutions. This CNA was later involved in an incident in which a cognitively intact, paraplegic resident reported verbal and physical abuse after requesting assistance with clothing and water, stating the CNA refused proper help and spilled water on the wheelchair, damaging items in the resident’s wallet, while the CNA gave a differing account of items sliding off a bedside table.
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.
Failure to Complete Required GCHEXS Fingerprint Check for CNA
Penalty
Summary
The facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for one CNA among ten employee files reviewed, despite a census of eighty residents and a written policy requiring criminal background checks for all employment candidates. The policy titled "Freedom of Abuse Abuse Prevention Fast Alert" dated 1/2025 states that, as part of pre-employment screening, all candidates must authorize a criminal background check for conviction of crimes. During record review with the Human Resources Manager (HRM), there was no documentation of a fingerprint records check for CNA BB, and the HRM confirmed that this CNA did not have a GCHEXS fingerprint check conducted. The HRM also stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining employee files. This failure to complete the required fingerprint background check for CNA BB resulted in noncompliance cited under F-Tag 600. No resident-specific medical histories, conditions, or direct resident care events were described in the report related to this deficiency.
Failure to Complete Required Background and Registry Checks for New Staff
Penalty
Summary
The facility failed to follow its own abuse, neglect, and misappropriation policy requiring pre-employment screening of all employees and volunteers before they worked with residents. The written policy stated that screening components included verification of references, certification and license verification, and criminal background checks. It further specified that, before new employees were permitted to work with residents, references and appropriate board registrations and certifications would be verified, and that the facility would not employ individuals found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment. The policy also required a criminal background check on all prospective employees, with significant findings resulting in denial of employment in accordance with state and federal regulations. Record review showed that one nursing assistant, hired on 8/5/25, did not have a criminal background check completed. Another staff member in dietary, hired on 9/26/25, did not have either a criminal background check or an Adult and Child Central Registry check completed. In an interview, the Business Office Manager confirmed that all new employees were required to have criminal background checks and Adult/Child Central Registry checks completed upon hire, and acknowledged that these checks had not been completed for the two identified staff members, despite the facility census being 27 residents.
Failure to Obtain Required FBI Background Check Prior to Hiring Staff
Penalty
Summary
The facility failed to thoroughly screen an individual prior to hire by not obtaining a required FBI criminal background check for one of five employee records reviewed (Employee E3). The facility’s Criminal Record/FBI Check Policy, revised March 14, 2022, required that a criminal record check and, when applicable, an FBI national check be processed for all staff members upon hire, specifying that an FBI check is required if the staff member is not a current Pennsylvania resident or has not been a state resident for the two years preceding the application. Review of Employee E3’s personnel record showed that this employee was hired on December 18, 2025, with no evidence that an FBI check had been initiated or completed. In an interview on February 20, 2026, at 12:43 p.m., the Nursing Home Administrator confirmed that Employee E3 had not been a Pennsylvania resident for the required two-year period and that the FBI check had not been completed, resulting in noncompliance with the facility’s policy and regulatory requirements related to screening for abuse, neglect, exploitation, or theft findings.
Failure to Complete Required Background Reference Check for LVN
Penalty
Summary
The facility failed to follow its Background Investigations policy by allowing a licensed vocational nurse (LVN 2) to work without completion of a required reference check. During an interview and employee file review with the Administrator, it was found that LVN 2’s reference check section in the employee file was not completed, despite LVN 2 having been employed at the facility since 2/13/24. The Administrator acknowledged that, per facility policy and procedure, reference checks should have been completed prior to the nurse beginning work. The written Background Investigations policy stated that job reference checks, drug screenings, licensure verifications, and criminal conviction record checks are to be conducted on all applicants for employment, and that applicants who do not consent to such investigations will not be considered for positions requiring them. The survey finding noted that this failure had the potential to expose residents to abuse, neglect, and mistreatment.
Failure to Screen and Exclude CNA with Prior Abuse Finding Leading to Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy by hiring and continuing to employ a CNA who had a documented finding of patient abuse on the state nurse aide registry and was listed on the OIG/medical exclusion and State Board lists. The CNA’s background screening report, completed prior to hire, clearly indicated a finding of patient abuse, yet the facility proceeded with employment. The facility also failed to obtain and document reference checks from previous and/or current employers or make reasonable efforts to uncover information about any past criminal prosecutions for this CNA, despite policy requirements to screen potential employees for a history of abuse, neglect, or mistreatment. The Administrator later stated he was not aware of the CNA’s abuse finding and that the facility does not hire nursing staff with such findings. The deficiency was further evidenced by an incident involving a resident with paraplegia and intact cognition, as shown by a BIMS score of 15 and clear communication abilities. According to an SBAR progress note, the resident reported that the CNA verbally and physically abused him, and the resident appeared anxious, intimidated, and uncomfortable with care. In an interview, the resident stated he had asked the CNA for help with clothing and water, and the CNA told him to stand up and help himself, then spilled water on the resident’s wheelchair and damaged items in his wallet, leaving the resident upset and anxious. In a separate interview, the CNA described an event in which a bottle of hot sauce and water slid from a bedside table and broke while the CNA was moving the table. These events, combined with the documented abuse finding on the CNA’s background screening and the lack of reference checks, demonstrate the facility’s failure to implement its abuse prevention policy not to employ or continue to employ anyone found guilty of abuse.
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.
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