Missing FBI Background Check for Agency Nurse Aide: The facility failed to complete an updated FBI background check for an agency NA before allowing the aide to work on the nursing unit. The aide had lived outside PA within the past two years, but the personnel file only contained an older FBI check and no updated check before the aide worked two shifts. The facility policy required background checks for all employees in accordance with State law.
Failure to Complete Timely Criminal Background Checks: The facility failed to properly screen employees by not completing timely criminal background checks before employment for three of five personnel files reviewed, including an RN, a COTA, and a NA. Facility policy required screening during the hiring process for a history of abuse, neglect, or mistreating residents, including criminal background checks. HR confirmed that one employee's checks were completed too far in advance to rule out criminal activity in a timely manner and another employee's background check was not completed before the start of employment.
Failure to Complete Pre-Hire License and Registry Checks: The facility failed to complete license and registry verifications before hire for three of four personnel files reviewed, including an LPN, a nurse aide, and a dietician. Facility policy required screening for abuse history and checking licensing boards and registries, and staff confirmed verifications should be completed prior to or upon hire.
Failure to timely investigate an allegation involving a resident being lowered to the floor by a NA. The resident had HTN, DM, anxiety, and required assist of 2 for transfers. Records showed the event was documented as having no injuries, but nursing notes lacked further detail, and the RNAC/former DON stated the investigation did not begin until the grievance was received later. Staff interviews indicated the LPN notified the supervisor at the time, but the timing and completeness of the investigation were unclear.
Failure to Complete Required Pre-Employment Screening: The facility did not complete required pre-hire screening for abuse, neglect, theft, and credential verification for several employees reviewed. Personnel records showed missing or delayed PA criminal background checks for two dietary aides, no documented PA nurse aide registry check for one nurse aide, and no documented PA RN licensure verification for two RNs prior to hire. The NHA confirmed the required checks were not completed as required.
Failure to Report and Investigate Alleged Physical Abuse: A resident developed large bruises on the R wrist and forearm after reporting that an employee threw off the covers and grabbed her arm while turning her during care. The employee denied using the resident’s arm, but the facility did not report the alleged abuse/neglect to the appropriate authorities or thoroughly investigate the incident, and the NHA and DON confirmed the findings.
Failure to Prevent Retaliation Against Staff: The facility failed to prohibit and prevent retaliation after staff attempted to speak with surveyors and report concerns. Although the handbook and posted notice included anti-retaliation language, five terminated employees had personnel files that did not support the reasons given for termination, and the NHA cited vague reasons such as professionalism, job abandonment, refusal to complete an admission, aggression, and alleged inciting of a verbal riot. Confidential interviews described management questioning staff about speaking with the surveyor, threats of immediate termination for calling the state, and a climate of fear related to complaints about staffing and resident care.
A resident with COPD and CKD, who was cognitively intact, reported an alleged sexual relationship with a nurse aide. Facility policy required any employee accused of abuse to be placed on leave with no resident contact, but after the allegation was reported and the aide was suspended, he still entered the resident's room. Staff and leadership later confirmed this contact occurred after the suspension and was inconsistent with policy.
A resident with a BIMS of 15 reported that a male RN gave her cough syrup without an order after she had a cough. Facility records showed no active or discontinued order for the medication, and the incident was later identified as possible medication misappropriation or medical neglect. The DON did not begin investigating immediately, the nurse continued working for several shifts after the allegation was reported, and the investigation was not completed until days later.
Facility records and staff interviews showed that required new hire screening was not followed for abuse prevention. An RN Unit Manager was hired before the criminal background check was completed, an LPN had no license verification in the file, and a nurse aide was hired before registry verification was completed. The NHA stated the facility allowed FBI background checks to be completed up to 90 days after hire and acknowledged the screening process was not followed as written.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.