Failure to Monitor Nurse Aide Certifications
Summary
The facility failed to monitor the North Carolina (NC) Nurse Aide (NA) Registry to ensure that five nurse aides employed at the facility maintained an active Nurse Aide I certification. This deficiency was identified through observation, record review, and staff interviews. Specifically, NA #6 was observed passing medications to a resident despite having an expired NA I certification. The review of NA #6's employment record and daily nursing assignment schedules confirmed that NA #6 had been working as a medication aide on multiple dates after the expiration of their certification. NA #6 stated that they were unaware of the expiration and believed the past Director of Nursing (DON) had submitted the renewal information. The Administrator confirmed that the DON was responsible for monitoring certifications, but due to frequent changes in the DON position, this responsibility had been neglected, leading to the oversight of NA #6's expired certification. The DON admitted to being unaware of the need to track certification expirations until recently. Further investigation revealed that four other nurse aides (NA #9, NA #4, NA #1, and NA #8) also had expired NA I certifications. An audit conducted by the facility confirmed that these nurse aides had worked multiple shifts with expired certifications. The DON, who had recently assumed the role, stated that she was not informed about the responsibility of monitoring certification expirations and was unaware of the expired certifications until the audit was conducted. The Administrator reiterated that the DON was responsible for this task, as outlined in the job description, but acknowledged that the limited orientation time might have contributed to the oversight. The facility's failure to monitor and ensure active certifications for its nurse aides resulted in multiple staff members working without the required credentials. This lapse in oversight was attributed to the frequent turnover in the DON position and the lack of clear communication regarding the responsibility for tracking certification expirations. The facility conducted an immediate audit to identify expired certifications and took steps to remove the affected nurse aides from their assignments until their certifications were renewed and verified as active on the NC Nurse Aide Registry.
Penalty
Resources
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Surveyors found that the facility failed to obtain and document an updated CNA registry verification before re-hiring a CNA who had previously been terminated. Review of the CNA’s personnel file showed an original registry check from the initial hire but no verification completed at the time of re-hire, and the administrator confirmed that no such documentation existed.
The facility failed to verify that an agency nurse aide had an active status on the Minnesota Nursing Assistant Registry before assigning her to a 7.5-hour day shift on a floor caring for multiple residents. The aide reported it was her first shift at the facility, and a registry search later showed her status had been inactive for over a year. The DON stated she relied on the staffing agency to send only registry-listed staff and acknowledged the facility did not verify active status for agency personnel, and the administrator confirmed that their process did not include checking current certification of agency aides. A requested facility policy related to this verification process was not provided.
A CNA worked an overnight 11 p.m. to 7 a.m. shift without an active CNA certification, in violation of federal nurse aide registry requirements and the facility’s job description requiring a valid CNA license. The DON had a personnel file printout indicating the CNA’s status was active and employable, but a concurrent CDPH registry search showed no matching data. Review of assignment and attendance sheets confirmed the CNA worked the shift after being called in by a Charge Nurse who did not realize the CNA had been removed from the schedule for lapsed certification. The DSD reported that CNAs with expired certifications are taken off the schedule and payroll and that this CNA had been informed of her limitations, yet she still worked the shift without valid certification.
Failure to Verify CNA Licensure at Hire: Facility staff failed to verify licensure at the time of hire for two CNAs reviewed. The HR Director said she was responsible for license verification and described a process involving review of a current license at interview, verification through the state department of health professions after management approval, and a second check by the employee’s manager after the CNA starts working with residents. The DON stated license verification at hire is important to confirm competency and prevent resident abuse.
The facility failed to ensure CMAs had current advanced gastrostomy certifications while administering medications via PEG tubes. A resident’s MARs over several months showed that three CMAs with expired or undocumented gastrostomy credentials repeatedly gave medications through a PEG tube. One CMA reported believing they were allowed to pass PEG tube meds and perform feedings, while the DON later stated that two CMAs supposedly had certifications that were not reflected in the nurse aide registry, and no documentation was produced to verify those credentials.
The facility failed to ensure that a CNA providing personal care was properly certified with the State of Ohio. A staff member originally hired as a housekeeper completed an online NATCEP but never took the state certification exam, and there was no CNA license listed for this individual on the Ohio Nurse Aide Registry. Despite this, the staff member worked multiple 12-hour shifts providing direct care. The DON and HR later acknowledged they were unaware the state test had not been completed and that required follow-up on certification status did not occur, affecting all residents in the facility.
Failure to Obtain CNA Registry Verification Prior to Re-Hire
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) registry verification was obtained prior to the re-hire of one CNA. Record review showed that this CNA had an initial hire date of 10/22/2012, a termination date of 04/19/2018, and a re-hire date of 10/10/2018. The personnel file contained a CNA registry verification dated 10/22/2012, corresponding to the original hire, but there was no documented evidence that a new CNA registry verification was obtained at the time of re-hire. During an interview on 03/18/2026 at 11:50 a.m., the administrator confirmed that the facility did not have documentation showing that a CNA registry verification was completed prior to re-hiring this CNA as required. This deficiency was identified for 1 of 2 CNA personnel records reviewed, specifically for the CNA who had a break in employment and was subsequently re-hired without updated registry verification documentation in the personnel record.
Failure to Verify Active Nurse Aide Registry Status for Agency Staff
Penalty
Summary
The facility failed to ensure that a nurse aide had a current competency evaluation on the Minnesota Nursing Assistant Registry before allowing her to work, affecting 1 of 1 nurse aides reviewed for registry verification and potentially all 71 residents. On 3/12/26 at 11:46 a.m., a nursing assistant (NA-A) reported it was her first shift at the facility, and the facility schedule for that date showed she was assigned to work a 7.5-hour day shift on the third floor, where 26 residents resided, with a total facility census of 71 residents. A Minnesota Nurse Aide Registry search, dated 3/13/26 at 11:45 a.m. and provided by the facility, showed NA-A’s registry status as inactive since 12/7/24. During interviews, the DON stated she trusted the staffing agency to send only staff who were on the registry and acknowledged the facility did not verify active status for agency staff, and the administrator confirmed that their process did not include verifying current certification of agency aides and that she expected only currently certified NAs would be sent. A facility policy related to this process was requested by surveyors but was not provided.
CNA Allowed to Work Overnight Shift Without Active Certification
Penalty
Summary
Surveyors identified that one CNA worked an overnight 11 p.m. to 7 a.m. shift without an active CNA certification, contrary to federal nurse aide registry requirements and the facility’s own job description, which requires a valid CNA certification. During interview and record review with the DON, the CNA’s Licensing & Certification Verification Detail Page in the personnel file showed an active, employable status with a future expiration date, which the DON had relied upon. However, when the DON searched the California Department of Public Health (CDPH) website during the same review, no data was found for the CNA, confirming that the CNA did not have an active certification on the registry at the time she worked the shift. Further review of the nursing assignment and attendance sign‑in sheets for the overnight shift confirmed that the CNA had signed in and worked that shift. The DON stated that the situation occurred because the evening shift Charge Nurse, attempting to cover a CNA call‑off, contacted this CNA, who was known for helping cover shifts, and did not recognize that she had been removed from the schedule due to lapsed certification. In a separate telephone interview, the DSD explained that CNAs with lapsed certifications are removed from the monthly schedule and payroll until their certification is valid, and that this CNA had been informed of what she could and could not do with an expired certification. The DSD also noted that the CNA should have known her status when the system would not allow her to clock in, yet she knowingly worked the shift without a valid CNA certification.
Failure to Verify CNA Licensure at Hire
Penalty
Summary
Facility staff failed to verify licensure at the time of hire for two of three CNA records reviewed, CNA #10 and CNA #11. On 2/23/26 at 9:00 a.m., staff were asked to provide evidence that licensure had been verified at the time of hire for both CNAs. According to the Director of Human Resources, CNA #10 was hired on 5/13/25 and CNA #11 was hired on 10/10/25, but despite multiple requests, no evidence of license verification at the time of hire was provided. On 2/23/26 at 5:02 p.m., the Administrator and DON were informed of the concern. The DON stated that license verification at the time of hire is important to make sure staff members are competent and to prevent resident abuse. On 2/24/26 at 12:19 p.m., the Director of HR stated she was responsible for overall license verification and explained that the potential employee brings a copy of their current license at the initial interview, she verifies it through the state department of health professions after management approval, and the employee’s manager verifies it again after the employee starts working with residents. The facility’s abuse policy stated that the Business Office Coordinator/designee performs background checks prior to hiring and that the community must not employ individuals with certain abuse-related findings or disciplinary actions against their professional license.
Expired and Unverified CMA Gastrostomy Certifications During PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) held current advanced gastrostomy certifications before administering medications via gastrostomy (PEG) tubes. Record review showed that CMA #1’s advanced gastrostomy certification had expired, yet the October 2025 MAR for Resident #1 documented that CMA #1 administered medications through the resident’s PEG tube on multiple dates. The facility’s undated Medication Administration policy stated that medications are to be administered by licensed nurses or other staff legally authorized to do so in the state, in accordance with professional standards of practice. The DON identified that 24 residents in the facility received medications through PEG tubes. Further review revealed that CMA #2 and CMA #3 also lacked documented, current advanced gastrostomy certifications while administering PEG tube medications. CMA #2’s certification had expired, but October and November 2025 MARs for Resident #1 showed that CMA #2 administered medications through the PEG tube on several dates, and CMA #2 stated they were allowed to pass medications and perform feedings via PEG tube. CMA #3’s advanced gastrostomy certification was also not current, yet October, November, and December 2025 MARs for Resident #1 documented multiple instances of PEG tube medication administration by CMA #3. The DON initially stated that CMA #1 was the only CMA not certified to work the medication carts and later reported that CMA #2 and CMA #3 did have certifications, but they were not in the nurse aide registry and would be verified with the testing school. However, the facility did not provide documentation confirming current gastrostomy certification for CMA #2 and CMA #3 by the time of the survey.
Unlicensed CNA Allowed to Provide Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that employed CNAs were properly certified with the State of Ohio, as required by facility policy and state regulations. Personnel record review showed that CNA #13 was originally hired as a housekeeper and later completed an online Nurse Aide Competency Evaluation Program (NATCEP), but there was no evidence she had obtained state certification. Timecard review for February 2026 showed CNA #13 worked multiple 12-hour shifts providing care. Review of the Ohio Nurse Aide Registry confirmed there was no current or expired CNA license for CNA #13. The facility’s policy on required training and certification stated that nurse aides must have successfully completed a state-approved NATCEP and either be awaiting certification results or be enrolled in a state-approved NATCEP within the first four months of employment, with certification to be verified through the state registry. Interviews further confirmed that CNA #13 was not licensed and was nonetheless providing personal care to residents. The DON acknowledged that CNA #13 had completed an online CNA program but never took the state test for licensure and verified that she was not licensed as a CNA. CNA #13 herself confirmed she was not licensed, was providing personal care, and reported that her scheduled state test had been cancelled during a government shutdown, and that the DON and Human Resources were not aware she had not completed the state test. Human Resources staff confirmed CNA #13 was not licensed and stated they failed to follow up after her test was cancelled. The facility census at the time was 65 residents, and the failure to ensure proper CNA licensure had the ability to affect all residents.
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