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F0607
D

Failure to Conduct Required Employee Reference Checks Prior to Hire

Oakland, California Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement written policies and procedures for screening prospective employees, specifically by not conducting reference checks for a Certified Nursing Assistant (CNA) prior to hire. Although the CNA's employment application listed a former employer and three personal references, Human Resources did not require or complete reference checks, despite the facility's policy stating that all potential employees should be screened for a history of abuse, neglect, exploitation, or mistreatment, including attempts to obtain information from previous employers and references. The Assistant Executive Director confirmed that reference checks were still required and should have been completed by the Director of Staff Development. Following the CNA's hire, multiple complaints were documented regarding the CNA's work performance and behavior, including discrepancies in vital sign documentation, refusal to follow infection control protocols, use of personal devices during work hours, and reports from residents and staff of rough or non-caring behavior and failure to respond to call lights. One resident with moderate cognitive impairment and dependence on renal dialysis reported rough and aggressive care, while another resident filed a grievance about delayed response to call lights. Staff interviews corroborated concerns about the CNA's attitude and lack of responsiveness.

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