Failure to Prevent Employment of Nurse with Active Disciplinary Action for Drug Diversion
Summary
The facility failed to ensure that it did not employ a nurse with an active disciplinary action on her professional license due to a history of drug diversion. Nurse #13 was hired despite having restrictions on her license imposed by the North Carolina Board of Nursing (NCBON) following an incident in 2021 where she admitted to diverting Oxycodone and having a substance abuse disorder. The facility was aware of these restrictions at the time of hiring, as they had obtained documentation from the NCBON outlining the disciplinary measures and employment limitations, including prohibitions on supervisory roles and certain types of employment. During her employment, Nurse #13 was involved in an incident where multiple Oxycodone tablets could not be accounted for while she was responsible for the care of Resident #2. The investigation revealed discrepancies in the number of tablets received and administered, with Nurse #13 unable to reconcile the missing medication or provide an adequate explanation. The facility reported the suspected drug diversion to the state agency and subsequently suspended and terminated Nurse #13. Interviews with facility staff and the NCBON compliance case analyst confirmed that Nurse #13's license restrictions were still in effect at the time of her hire and during the incident. The restrictions included specific employment limitations due to her participation in the Alternative Program for Chemical Dependency. Despite these known restrictions and her disciplinary history, the facility proceeded with her employment, which led to the deficiency identified in the report.
Penalty
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The facility failed to avoid employing an individual with violent convictions. Employee 1’s background screening showed a prior battery conviction, and the HRM confirmed the employee had admitted to two violent crimes before hire. Employee 1 was hired through the NAT program, worked directly with residents, and was observed on a scheduled shift in scrubs. The DSD stated a community member later notified the facility that Employee 1 had been convicted of a violent felony.
The facility employed an HRM and a DON despite criminal history concerns tied to theft and fraud. The HRM was later found to have been indicted for telecommunications fraud and grand theft and did not report the charges to the Administrator, while the DON’s file and background information showed theft-related history and incomplete disclosure on the application. Interviews confirmed leadership was aware of the issues after hire, and the facility policy prohibited hiring professionals with findings related to abuse, neglect, exploitation, or misappropriation of property.
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.
Incomplete Background Check Before Hire: The facility failed to ensure a thorough criminal background check was completed before hire for a CNA whose SING form showed criminal convictions but lacked further research documentation to confirm eligibility to work. The Administrator acknowledged the facility did not have the completed background check results, and the facility policy required Iowa criminal record and dependent adult/child abuse registry checks prior to hire.
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 Screen Out Employee With Violent Convictions
Penalty
Summary
The facility failed to not employ an individual who had been found guilty of abuse or mistreatment by a court of law for one of three sampled employees. Employee 1’s background screening report, dated 2/9/26, showed a 2019 conviction for battery, and the HRM confirmed that battery was consistent with physical abuse. The HRM also confirmed that Employee 1 admitted to having two convictions for violent crimes prior to hire. Employee 1 was hired through the facility’s NAT program on 2/10/26 and worked directly with residents. The DSD stated that on 6/20/26 a community member notified the facility that Employee 1 had been convicted of a violent felony. During observation on 6/25/26, Employee 1 was seen in the hallway wearing scrubs and the DSD stated Employee 1 was working a scheduled shift with residents. Employee 1 stated he had been working in the facility directly caring for residents since March 2026 and reported prior convictions for battery in 2019 and assault with a deadly weapon in 2021.
Staff Hired With Criminal History Concerns
Penalty
Summary
The facility failed to employ staff free of disqualifying offenses after hiring Human Resource Manager #439 and later learning she had been indicted for telecommunications fraud and grand theft. Her personnel file showed a hire date of 10/08/25, and the record included court docket information showing the indictment, pre-trials, and bail posting. An email from HRM #439 to the Administrator stated she had been accused by a previous employer of paying her son for time he was not employed there, that she later received a court summons, and that she was told to plead guilty and accept probation with restitution. During interview, the Administrator and Corporate RN stated that HRM #439 did not have disqualifying offenses on her background check at hire, but that the facility received an anonymous tip about the grand theft charge on 04/01/26 and suspended her that day. HRM #439 confirmed she had been notified of the charges in mid-December 2025 and did not tell the Administrator about them. The facility also employed a previous DON despite background information and application responses that raised concerns about criminal history. The employee file for Previous DON #442 showed an application for an RN position in which she answered “expungement” to the question about prior convictions or guilty pleas, with no further details. The facility’s BCI log showed her application and hire information, and later review of the criminal history record check revealed an arrest for a theft misdemeanor. Regional RN #412 stated Previous DON #442 had served as ADON and then as DON when the position became vacant, and that staff had reported concerns about her management style. Regional RN #412 also stated she was unable to provide evidence of personal care standards after being made aware of the background check results. A phone interview with Previous DON #445 added that she had started as a PRN nurse, later became a unit manager, then ADON, interim DON, and finally DON. She stated she had a theft violation that was expunged about 15 years ago and that the facility did not request additional information or character references before hiring her. The Administrator confirmed Previous DON #442 quit by text message and stated she was quitting effective immediately. The facility policy stated it would not proceed with hiring professionals found guilty or with active disciplinary action related to abuse, neglect, exploitation, mistreatment, or misappropriation of resident property, and the deficiency was cited under complaint investigations.
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.
Incomplete Background Check Before Hire
Penalty
Summary
The facility failed to ensure a thorough background check was completed before hire for 1 of 3 staff personnel files reviewed. Staff A, a CNA with a start date of 9/9/25, had an Iowa Criminal History Record Check Request SING form dated 9/3/25 that showed a history of criminal convictions, but the form did not include further research documentation to confirm whether Staff A could work at the facility. The Administrator reported that the facility did not have a copy of Staff A's completed background check with results showing whether further research was required. Facility policy titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, states the facility will conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents prior to hire. The Administrator stated the results had been requested from the Iowa Department of Public Service on 4/10/26, but due to a system change, the results were not able to be obtained.
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.
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