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.
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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.
The facility employed a cook who had a prior felony conviction for aggravated assault with a deadly weapon, despite state law barring such individuals from employment and the facility’s own abuse/neglect policy prohibiting hiring persons found guilty of abuse, neglect, exploitation, misappropriation, or mistreatment. The cook’s personnel file showed multiple criminal history checks, and the cook reported serving four years in jail for the offense. The HR Director reviewed the criminal history and identified both a deferred adjudication and a subsequent conviction with a four-year confinement term, concluding this created a lifetime employment bar. The DON stated the HR Director was responsible for criminal history checks and the Administrator for oversight of that process, while the Administrator maintained his belief that the cook remained eligible for employment based on his interpretation of the criminal history and deferred adjudication.
The facility did not complete a required Georgia Criminal History Check System (GCHEXS) fingerprint background check for a CNA, as identified during review of ten employee files with a census of eighty residents. The facility’s abuse-prevention policy required criminal background checks for all employment candidates, but there was no documentation of a fingerprint records check for this CNA. The HR manager, who is responsible for background and fingerprint checks and maintaining employee files, confirmed that the GCHEXS fingerprint check had not been conducted, resulting in a deficiency under F-Tag 600.
A contracted PTA with a court conviction for corporal injury remained on the rehab staff schedule and was observed working in the rehab gym. The DOR knew of the citation on the PTA’s PTBC license, and the DSD later confirmed the citation involved a misdemeanor for corporal injury but relied on the DOR’s assurance that the PTA could keep working. The facility’s abuse policy stated it does not employ anyone found guilty of abuse or mistreatment by a court of law.
The facility did not follow its own policy requiring pre-employment screening, including criminal background checks and Adult/Child Central Registry checks, for all new staff before they worked with residents. Record review showed that a NA was hired without a criminal background check, and a dietary staff member was hired without a criminal background check or Adult/Child Central Registry check. The BOM confirmed that these checks were required for all new employees but were not completed for these two staff members.
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.
Employment of Staff Member With Disqualifying Aggravated Assault Conviction
Penalty
Summary
The deficiency involves the facility’s failure to prevent the employment of an individual with a disqualifying criminal conviction for aggravated assault with a deadly weapon. The employee, referred to as Cook A, was hired with a documented hire date of 11/04/24 and worked in the facility until 04/24/26. Her personnel file showed that criminal history checks were conducted on three occasions: at hire and on two later dates. During interviews, Cook A stated she had been convicted of aggravated assault with a deadly weapon in the late 1990s, served four years in jail from 1998 to 2002, and was released in 2002. The HR Director reported that she had pulled and reviewed Cook A’s criminal history and stated that, based on the report, Cook A would not be eligible for hire if she applied at the time of the survey because she had a felony from 1996. The HR Director later reviewed the criminal history in detail, noting an arrest for aggravated assault with a deadly weapon under Texas Penal Code 22.02(a)(2), classified as a second-degree felony. The record showed an initial court disposition of deferred adjudication, followed by another court entry reflecting a conviction for aggravated assault with a deadly weapon, a four-year term of confinement, and a sentence expiration date in 2002. The HR Director concluded that this constituted a lifetime bar to employment. Other facility staff provided information about the hiring and background check process. The Dietary Manager stated that the HR Director and Administrator review background checks and inform department heads whether an applicant is acceptable for hire, and that the prior HR Director had indicated Cook A was acceptable. The DON stated that the HR Director was responsible for ensuring criminal history checks on new hires and annually, and that the Administrator was responsible for ensuring the HR Director reviewed criminal history correctly. The Administrator stated his belief that Cook A was eligible for hire and that his understanding of her criminal history was that she was convicted, served time, and then likely received deferred adjudication. The report cites the Texas Health and Safety Code, Chapter 250.006, which bars employment of persons convicted of aggravated assault under Penal Code 22.02, and the facility’s own abuse/neglect policy, which prohibits employing individuals found guilty of abuse, neglect, exploitation, misappropriation, or mistreatment by a court of law.
Failure to Complete Required GCHEXS Fingerprint Check for CNA
Penalty
Summary
The facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for one CNA among ten employee files reviewed, despite a census of eighty residents and a written policy requiring criminal background checks for all employment candidates. The policy titled "Freedom of Abuse Abuse Prevention Fast Alert" dated 1/2025 states that, as part of pre-employment screening, all candidates must authorize a criminal background check for conviction of crimes. During record review with the Human Resources Manager (HRM), there was no documentation of a fingerprint records check for CNA BB, and the HRM confirmed that this CNA did not have a GCHEXS fingerprint check conducted. The HRM also stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining employee files. This failure to complete the required fingerprint background check for CNA BB resulted in noncompliance cited under F-Tag 600. No resident-specific medical histories, conditions, or direct resident care events were described in the report related to this deficiency.
Contract PTA with Abuse Conviction Continued Working
Penalty
Summary
The facility failed to prevent employing a contracted Physical Therapy Assistant (PTA) who had been found guilty by a court of law of abuse or mistreatment. The PTA remained on the facility’s rehab staff schedule and was working in the rehabilitation gym when surveyors observed and interviewed staff on 3/18/2026. Record review showed the PTA’s California Physical Therapy Board license had a citation issued on 2/5/2025 for a misdemeanor conviction of inflicting corporal injury, along with a citation for failure to notify the Board within 30 days of the conviction. The Director of Rehabilitation stated the rehab staff were employed by a contract rehab company and confirmed the PTA was working at the facility despite the citation. The DSD stated she saw the citation during the license renewal period, could not open the citation on the Board website, and relied on the DOR’s assurance that the PTA could continue working. The facility’s Abuse Prevention/Prohibition policy stated it does not employ anyone found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. The Therapy Services Agreement with the contract rehab company stated the company would ensure therapists met all applicable federal and state laws, rules, and regulations.
Failure to Complete Required Background and Registry Checks for New Staff
Penalty
Summary
The facility failed to follow its own abuse, neglect, and misappropriation policy requiring pre-employment screening of all employees and volunteers before they worked with residents. The written policy stated that screening components included verification of references, certification and license verification, and criminal background checks. It further specified that, before new employees were permitted to work with residents, references and appropriate board registrations and certifications would be verified, and that the facility would not employ individuals found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment. The policy also required a criminal background check on all prospective employees, with significant findings resulting in denial of employment in accordance with state and federal regulations. Record review showed that one nursing assistant, hired on 8/5/25, did not have a criminal background check completed. Another staff member in dietary, hired on 9/26/25, did not have either a criminal background check or an Adult and Child Central Registry check completed. In an interview, the Business Office Manager confirmed that all new employees were required to have criminal background checks and Adult/Child Central Registry checks completed upon hire, and acknowledged that these checks had not been completed for the two identified staff members, despite the facility census being 27 residents.
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