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F0607
E

Failure to Complete Timely Employee Background Checks

Lake Geneva, Wisconsin Survey Completed on 11-06-2025

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 its abuse prevention policy and procedure regarding timely employee background checks for one of eight employees reviewed. Specifically, a dietary aide who was also working as an activity aide did not have an updated background check completed within the required four-year interval. The employee was initially hired with all required background check documentation completed at that time, but no subsequent background check was performed by the four-year deadline as mandated by facility policy. This lapse was identified during a review of personnel files requested by the surveyor. The Director of Nursing acknowledged the oversight when informed, and the Human Resources representative confirmed that background checks are their responsibility. The deficiency was confirmed when the Nursing Home Administrator provided background check forms for the employee that were only completed on the day of the survey, rather than within the required timeframe.

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