Failure to Complete Required Caregiver Background Checks Before Staff Worked With Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement its written Abuse/Neglect/Exploitation policy requiring screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property through background, reference, and credential checks. Surveyor review of 10 staff files on 3/11/26 showed that 6 staff members did not have timely or properly completed caregiver background checks. One CNA hired on 6/24/16 had a Background Information Disclosure (BID) form dated 6/23/16, but the Department of Justice (DOJ) and Government Findings (GF) reports were not completed until 3/11/26, after the surveyor requested them, and not within the required four-year interval. Another CNA hired on 1/29/26 had a BID form dated 1/30/26, completed after the hire date, and there was no evidence that DOJ or GF reports were requested. A third CNA hired on 11/2/04 had a BID form completed on 8/26/16, but the DOJ and GF reports were not completed until 12/29/20, which was not within the last four years. An activity aide hired on 1/24/26 had a BID form dated 1/26/26 and DOJ/GF reports dated 1/27/26, all completed after the hire date, meaning the aide worked with residents before completion of the background check. A maintenance staff member hired on 12/8/25 had DOJ and GF reports dated 12/9/25, after the hire date, and worked in resident care areas before the background check was completed. Another CNA hired on 1/6/26 had DOJ and GF reports dated 1/8/26, also after the hire date. In an interview, the NHA and DON confirmed that the previous business office manager had been responsible for background checks, that this person had left employment a few weeks earlier, and that background checks are required every four years and must be completed before staff work with residents or in resident care areas.
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