The certified nursing assistant, identified as CNA-C in inspection records, began working at the 1226 Berlin Street facility on August 26. Federal inspectors discovered on October 27 that no out-of-state background search had been completed, despite the worker's disclosure that they had lived outside Wisconsin within the previous three years.
The gap violated federal requirements designed to prevent abuse in nursing homes. Bethany Home's own policy, revised in April 2021, explicitly requires background, reference and credential checks for all potential employees and contracted temporary staff.
CNA-C had completed a Background Information Disclosure form on June 11 when beginning work for the staffing agency. The form clearly indicated the assistant had lived outside Wisconsin in the previous three years, triggering the need for an expanded background search.
But no such search occurred.
Director of Nursing DON-B told inspectors the facility relies on staffing agencies to ensure background checks are completed correctly before workers arrive. The nursing director scrambled to obtain a national background search on October 27, the same day inspectors questioned the missing documentation.
"The facility relies on the agency to ensure background checks are done correctly prior to staff working at the facility," DON-B explained to surveyors at 11:45 AM.
The responsibility for tracking background check compliance falls to Director of Human Resources DHR-E, who acknowledged the system's failure. DHR-E told inspectors they try to maintain agency staff background check files on-site and attempt to catch anything that appears incorrect.
"DHR-E tries to keep agency staff background checks on site and tries to catch anything that looks incorrect," according to the inspection report.
But the human resources director verified that no out-of-state background check had been provided or completed for CNA-C. More significantly, DHR-E confirmed the facility should have obtained complete background check information before the agency worker began caring for residents.
The violation represents what inspectors classified as "minimal harm or potential for actual harm" to residents. Federal regulations require nursing homes to develop and implement comprehensive policies to prevent abuse, neglect and theft.
Background checks serve as a critical first line of defense in identifying workers who may pose risks to vulnerable residents. The checks are particularly important for agency staff, who may work at multiple facilities and have less direct oversight than permanent employees.
Bethany Home's policy acknowledges this reality by requiring background verification for both employees and contracted temporary staff. The policy makes no distinction between permanent workers and agency personnel in its background check requirements.
The two-month gap meant CNA-C provided direct care to nursing home residents while facility administrators lacked complete information about the worker's background. Agency staff typically assist with basic care tasks including feeding, bathing, toileting and medication administration under nursing supervision.
The timing of the discovery proved particularly problematic. Inspectors found the violation during a complaint investigation on October 27, the same day administrators finally obtained the missing background search. The rapid response suggested facility leaders recognized the seriousness of the oversight once confronted with the gap.
Federal inspectors reviewed background check information for eight staff members during their investigation. CNA-C was the only worker found to have incomplete documentation, suggesting the problem was not systematic but represented a specific failure in the verification process.
The facility's reliance on staffing agencies for background check completion created a dangerous assumption. While agencies may conduct their own screening, nursing homes remain responsible for ensuring all workers meet federal safety requirements before providing resident care.
DHR-E's admission that the facility "should have complete background check information prior to agency staff starting" underscores this responsibility. The statement reveals administrators understood the requirement but failed to enforce it consistently.
The violation occurred despite Bethany Home's written commitment to comprehensive screening. The facility's abuse prohibition policy specifically addresses background checks for temporary contracted staff, eliminating any ambiguity about requirements for agency workers.
Agency staffing has become increasingly common in nursing homes facing worker shortages. But the increased reliance on temporary workers makes background check verification more complex, as facilities must coordinate with multiple agencies while maintaining consistent safety standards.
The inspection classified the violation as affecting "few" residents, though the report does not specify exactly how many people received care from CNA-C during the two-month period. Agency workers typically rotate among different units and shifts, potentially interacting with numerous residents.
Background check gaps can have serious consequences beyond immediate safety risks. Incomplete screening may violate state licensing requirements and federal participation standards, potentially affecting the facility's ability to accept Medicare and Medicaid payments.
The October 27 inspection was conducted in response to a complaint, though the report does not detail the nature of the original concern that prompted the investigation. Complaint-driven inspections often uncover additional violations during the review process.
Bethany Home must now develop a plan of correction addressing the background check failure. The facility has 14 days from receiving the inspection report to submit its corrective action plan to state health officials.
The violation highlights ongoing challenges nursing homes face in managing agency staff oversight. As facilities increasingly depend on temporary workers to maintain adequate staffing levels, ensuring complete background verification becomes more complex but no less critical.
CNA-C continues to work at the facility with the national background search now complete. But the two-month gap raises questions about how many other agency workers may have provided care with incomplete screening at Bethany Home and similar facilities across Wisconsin.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bethany Home from 2025-10-27 including all violations, facility responses, and corrective action plans.