Failure to Screen and Exclude CNA with Prior Abuse Finding Leading to Resident Abuse Allegation
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN with a nurse aide registry finding of abuse, neglect, or misappropriation was allowed to work after the facility received notice that she was ineligible for LTC employment. Schedules, time punches, and observation showed the LPN working on multiple shifts and providing care to 15 residents on two hallways, while the DON initially believed the active nursing license allowed her to work.
Failure to complete pre-employment background check for the ADM. The DON stated there was no evidence of a background check before the ADM began working, even though facility policy required background and criminal checks to be initiated within two days of an offer of employment and completed prior to employment. The DON stated the DSD was responsible for initiating background checks for all employees, and a background report was not completed until years later, when the discrepancy was discovered.
The facility failed to prevent a volunteer with a sex offense history from providing karaoke services. Facility staff stated the volunteer had been performing at the facility for at least two years, even though the ADON and DON acknowledged the individual was on the sex offender registry and should not have been volunteering. The facility policy required screening of volunteers and documentation of that screening.
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 document Ohio Abuse Registry screening for multiple employees, including the Administrator, former DON, Admissions, HR, two CNAs, and an RN. HR confirmed the files had no evidence of the checks, and the Administrator said the binder with screening documentation could not be located after the former DON left abruptly. The facility policy required screening potential employees for abuse, neglect, exploitation, or misappropriation of resident property.
Ineligible LPN Worked After Abuse Finding
Penalty
Summary
The facility failed to ensure that staff with a finding of abuse, neglect, exploitation, or theft were not working in the facility. Review of the state nurse aide registry showed that LPN #130 was not in good standing and had been found to have committed abuse, neglect, or misappropriation, making the nurse ineligible to be employed by a long-term care facility in any capacity. The facility received email notification from the Ohio Department of Health on 07/22/26 confirming this ineligibility, but facility schedules and time punches showed LPN #130 worked on 07/22/26, 07/23/26, and 07/25/26, including shifts on [NAME] and [NAME] hallway. During observation and interview on 07/27/26, LPN #130 was seen working on [NAME] and [NAME] hallway and stated she was not aware she was not supposed to work at any long-term care facilities due to the adverse action on the nurse aide registry. She denied being told by management on or around 07/22/26. The DON stated she believed the nurse could work because she had an active nursing license and was confused by the last name listed in the registry, but later confirmed LPN #130 was ineligible to work in long-term care facilities. The facility stated that 15 residents on [NAME] and [NAME] hallways received care from LPN #130.
Failure to Complete Pre-Employment Background Check for Administrator
Penalty
Summary
The facility failed to conduct a background check during the pre-employment screening for the Administrator, who was hired on 4/2/2012. During a concurrent interview and record review, the DON stated there was no evidence of a background check before the Administrator began working in the facility, and that all staff were required to complete a background check on hire. The DON also stated the DSD was responsible for initiating background checks for all employees during pre-employment screening. During a later interview, the DON stated a background check was completed for the Administrator in December 2017 after the facility discovered the discrepancy. Review of the Administrator’s Background Report dated 12/14/2017 showed no red flags or disqualifying records. Facility policy titled Background Screening Investigations stated background and criminal checks are initiated within two days of an offer of employment and completed prior to employment, and the Abuse Prevention Program policy stated the facility will conduct employee background checks as part of resident abuse prevention.
Volunteer with sex offense history allowed to provide services
Penalty
Summary
The facility failed to ensure a volunteer with a documented history of abuse-related adverse action was not allowed to volunteer at the facility. Facility policy stated background, reference, and credential checks would be conducted on potential employees, contracted temporary staff, students, volunteers, and consultants, and that documentation of screening would be maintained. However, a review of the sex offender registry showed Volunteer #1 had been convicted of lewd or indecent proposals/acts to a child and was a registered sex offender. Despite this, the activities director stated Volunteer #1 had been performing karaoke at the facility on Thursday afternoons for at least two years. The ADON stated the volunteer was on the sex offender registry and should not have been allowed to volunteer, and the DON also stated the volunteer was a registered sex offender and should not have been volunteering at the facility.
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 Document Abuse Registry Screening
Penalty
Summary
The facility failed to ensure employees were screened for a history of abuse on the Ohio Abuse Registry. Review of personnel files showed no evidence of registry screening for the Administrator, the former DON #400, Admissions #76, HR #74, CNA #32, CNA #34, and RN #104. During an interview, HR #74 confirmed the personnel files contained no evidence of abuse registry checks. The Administrator stated the former DON left abruptly and the facility was unable to locate the binder that was supposed to contain evidence that staff had been checked against the Ohio Abuse Registry. Review of the facility policy titled Abuse, Neglect, and Exploitation showed the facility screened potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property and maintained documentation of that screening.
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