Ararat Nursing Facility

Based on interview and record review, the facility failed to complete a background check for three of three sampled employee files (Licensed Vocational Nurse 1 or LVN1, Registered Nurse 1 or RN1, and Certified Nurse Assistant 1 or CNA1).This deficient practice has the potential to place residents at risk for abuse, neglect, exploitation, or misappropriation of resident property.Findings:During a review of LVN 1's Employee file, Employee file indicated LVN 1 was hired on 6/5/2021.

The employee file indicated no documented evidence of criminal background checks. LVN 1 is currently employed in the facility.

During a review of RN 1's Employee file, Employee file indicated RN 1 was hired on 3/18/1997.

The employee file indicated no documented evidence of a criminal background check. RN 1 is currently employed in the facility.

During a review of CNA 1's Employee file, the Employee file indicated CNA 1 was hired on 2/16/1998.

The employee file indicated no documented evidence of a criminal background check. CNA1 is currently employed in the facility.

Durin an interview with the Director of Staff Development (DSD) on 8/12/2025 at 9:10 a.m., the DSD stated, LVN 1, RN 1, and CNA 1 did not have a background check in their employee files because prior to 2014, the facility did not require new hires to have a background check. DSD stated, she was not working in the facility at that time and does not know what happened prior to 2014.

The DSD stated she will submit a background check for the staff.

The DSD stated all staff in the facility should have a background check because they need to be cleared from any abuse prior to start of work in the facility.

During an interview with the Administrator (ADMIN) on 8/12/2025, ADMIN stated the Facility did not conduct any background checks prior to the year 2014 but was not able to provide a policy to corroborate his statement.

During an interview with Director of Nurses (DON) on 8/13/2025 at 4:10 p.m., the DON stated a background check was immediately ordered for LVN 1, RN 1, and CNA 1.

The DON stated it is important to have background checks on all staff working in the facility because they need to be cleared of any criminal findings and also be cleared from any abuse.A record review of the facility's policy and procedure titled, Staff Screening, dated August 1, 2023, indicated the facility will utilize reasonable and prudent criminal background screening and reference checks for prospective staff, contractors/consultants, registry/temporary staff, and volunteers.

Prior to employment or commencement of a contract, the Facility will verify and document or obtain a copy, if applicable, of the following information that may include, but is not limited to: criminal background checks.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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