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F0607
E

Failure to Complete and Maintain Required Background Checks for Employees

Willow Park, Texas Survey Completed on 04-09-2025

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 implement and maintain written policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, for two employees, there was no evidence that criminal history checks or checks of the state nurse aide registry (NAR/EMR) were completed prior to offering employment, as required by facility policy. Employee files for these individuals did not contain documentation of these checks, despite their hire dates being after the policy's effective date. Interviews with the DON and HR revealed that the required background and registry checks were not located in the employee files, and both were unsure why the documentation was missing. The HR staff confirmed responsibility for completing and maintaining these checks, and the administrator stated that monitoring of background checks had only been occurring for new hires. The administrator acknowledged that staff turnover in HR and administration contributed to the failure to ensure these checks were completed and maintained, resulting in the potential for residents to receive care from individuals who may not have been eligible for employment.

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