Bethany Home: Background Check Failure for Agency CNA - WI
CNA-C's first day at Bethany Home was August 26, 2025. Before that, when she began working for the staffing agency, she had filled out a Background Information Disclosure form on June 11 indicating she had lived outside Wisconsin within the previous three years. That disclosure triggered a requirement for an out-of-state or national background search. Nobody ran one.
Two months passed.
On October 27, an inspector reviewed background check records for eight staff members and pulled CNA-C's file. The out-of-state search wasn't there. At 11:45 that morning, the inspector sat down with the Director of Nursing, identified in the inspection report as DON-B. The director handed over a national background search. It was dated that day, October 27, the same morning the inspector had arrived.
DON-B's explanation was direct: the facility relies on the agency to make sure background checks are done correctly before staff begin working on site. The Director of Human Resources, DHR-E, handles all background check paperwork once it comes in from the agency.
DHR-E, interviewed fifteen minutes later, described a system built on best efforts and hope. DHR-E said she tries to keep agency staff background check records on site and tries to catch anything that looks incorrect. She confirmed that no out-of-state check had been provided or completed for CNA-C. She also confirmed the facility should have that complete information before agency staff ever start working there.
Should have. Didn't.
The gap between what Bethany Home's own policy requires and what actually happened is not ambiguous. The facility's Abuse Prohibition policy, revised in April 2021, states that background, reference, and credential checks shall be conducted on potential employees and contracted temporary staff. CNA-C was contracted temporary staff. The disclosure form she signed made clear she had recently lived out of state. The required search did not happen.
What makes this more than a paperwork problem is what background checks are designed to catch. They exist because nursing home residents, many of them unable to speak for themselves or advocate for their own safety, depend on facilities to screen out workers who have harmed people before. An out-of-state check isn't a formality. It's the mechanism for finding out whether someone has a history of abuse, neglect, or exploitation in a jurisdiction where Wisconsin's own registry wouldn't show it.
CNA-C worked at Bethany Home for sixty-two days before anyone ran that check.
The inspection report does not say what, if anything, the national search completed on October 27 turned up. It does not say whether CNA-C was removed from the schedule while the check was pending, or whether she continued working after the inspector's visit. It does not describe any resident harm connected to CNA-C's time at the facility. Inspectors rated the violation at the lowest level of harm, minimal harm or potential for actual harm, affecting few residents.
But the rating reflects what inspectors could document, not what the absence of a background check might have allowed.
The structure that failed here is worth understanding. Bethany Home had a policy. The agency had a process. DHR-E was trying to catch errors. DON-B believed the agency was handling it. And CNA-C, who disclosed on her paperwork that she had lived out of state, worked two months of shifts at a nursing home in Waupaca while the check that her own disclosure form required sat undone.
Nobody caught it. Nobody flagged it. The only reason it surfaced was because an inspector came in and looked at eight files.
DHR-E's statement that she "tries" to catch anything that looks incorrect is not a quality assurance system. It is one person eyeballing paperwork from a staffing agency and hoping nothing slips through. In this case, something slipped through for two months, and it slipped through cleanly enough that it took an outside reviewer to find it.
The facility's position, as described by DON-B, is that the responsibility sits with the agency. That may reflect how the relationship is structured contractually. It does not reflect how the regulation works. Bethany Home is the licensed nursing facility. The residents in its care are Bethany Home's residents. When an agency worker comes through the door to provide hands-on care to those residents, the obligation to know who that person is belongs to the facility, not to the agency that sent them.
DHR-E acknowledged this directly. She confirmed that the facility should have complete background check information before agency staff start working. That's not a disputed point. What's disputed, implicitly, is who was supposed to make sure it happened.
The answer, under the facility's own policy and under federal requirements for nursing homes participating in Medicare and Medicaid, is Bethany Home.
The inspection was a complaint survey, meaning someone contacted regulators before the October 27 visit. The inspection report does not describe what the complaint alleged or whether it was related to the background check finding. It is possible the background check gap was discovered incidentally, as inspectors reviewed records in response to a different concern entirely.
What the report does make clear is the sequence: CNA-C disclosed she had lived out of state. The agency did not run the required search. The facility did not verify the search had been run. CNA-C worked sixty-two days of shifts. An inspector arrived. The Director of Nursing produced a national background check completed that morning.
The residents CNA-C cared for during those two months had no way of knowing any of this. They could not have known that the screening designed to protect them had not been completed, that the gap existed, or that it was closed only because someone showed up with a clipboard and started asking questions.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
Bethany Home in Waupaca, WI was cited for violations during a health inspection on October 27, 2025.
CNA-C's first day at Bethany Home was August 26, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.