Uncertified Nurse Aides Used as Independent Direct Care Staff
Summary
The deficiency involves the facility’s failure to ensure that nurse aides (NAs) were properly certified, trained, and deemed competent before independently providing direct resident care. The facility’s own undated Nursing Assistant Job Description stated that uncertified NAs were expected to provide routine daily nursing care only in areas where they had received clinical instruction and demonstrated competence, and that general direct resident care duties could not be performed until theory and competency skills were accomplished. The job description also required that NAs be enrolled in a state-approved Nurse’s Aide Training Program (NATP) and maintain clinical competency while enrolled. However, record review showed that Facility 3 did not have a California Department of Public Health (CDPH)–approved NATP or serve as a clinical training site, despite employing NAs in training and assigning them to direct care roles. Surveyors’ review of hiring dates, NATP graduation dates, and state certification dates for seven NAs showed that multiple NAs were assigned to independent resident care duties before they were state certified. NA 1, NA 2, and NA 3 were hired, later graduated from NATP, and became certified on a later date, but were assigned to resident care—sometimes unpaired with a CNA—before certification. NA 4 was hired and remained uncertified for months while being scheduled to work independently on a unit without pairing to a specific CNA. NA 5 graduated from NATP but never became certified before resigning, yet was assigned to independent unit work and 1:1 resident care. NA 6 and NA 7 had graduated from NATP and remained uncertified; they reported working as NAs at Facility 3 until certification, and were observed at the facility on a scheduled shift, although they did not appear on the written schedule provided for review. Interviews with staff further demonstrated that uncertified NAs were being used as direct care providers. The Director of Staff Development (DSD 1) stated that graduated NAs could do everything a CNA could do except operate machinery like a Hoyer lift, and that they could perform 1:1 care, accompany residents to appointments, and “pretty much everything a CNA can do.” The scheduler confirmed that NAs were scheduled full time and placed into CNA rotation slots. The NATP instructor and DSD 2 from Facility 2 stated that uncertified NAs were not supposed to provide hands-on care without CNA or licensed nurse supervision and that they were unaware NA graduates were not permitted to work at Facility 1 or 3 prior to certification. NA 3 reported performing direct resident care, including touching and changing residents with CNA supervision, and described confusion about what NAs were allowed to do, noting that the facility had not assessed skill competencies or provided orientation during their work as an NA. The Governing Body’s representative acknowledged that Facilities 1 and 3 were not approved NATP sites and agreed that NAs should not be feeding and changing residents, while also confirming that the Administrators and Governing Board were responsible for ensuring NATP and NA hiring followed federal and state regulations.
Penalty
Resources
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Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
The facility failed to ensure nurse aides were fully trained and competent or appropriately enrolled and supervised before working independently, as CNA students were scheduled and counted as regular CNAs with their own hall assignments. Staff interviews indicated that students who had not completed CNA classes or state testing were routinely used to fill CNA positions, contributing to perceived short staffing and workload issues. A CNA student reported being in an in-house CNA course for 1–2 months, completing online coursework and limited clinical days, yet being independently assigned to a hall and additional rooms on other days that were treated the same as clinical hours. The ADON and DON stated that once classroom work and skills sign-offs were done, they considered students able to work their own assignments and counted them as CNA staff on the schedule, affecting all residents in the building.
A nurse aide was hired and continued working without completing the required training and competency evaluation program within 4 months of hire. HR stated the aide was told how to obtain certification and that certification was required within 4 months, but no verification of completion was in the file, and the DON acknowledged the aide had worked longer than 4 months without certification.
The facility did not obtain direct verification from the Pennsylvania Nurse Aide Registry before allowing an agency nurse aide to work, despite a policy requiring verification of active licenses and certifications. Instead, the facility relied on a staffing agency that accepted an uploaded, falsified nurse aide license without independently verifying it. This led to an unlicensed nurse aide working multiple shifts in the facility before the issue was identified by the state Attorney General's Office and the aide was removed from the schedule.
The facility failed to ensure 2 nurse aides were certified within the required timeframe. Record review showed one aide had worked full time since hire without CNA certification, and another had worked full time with no evidence of certification. The DON and ADON stated they knew both aides had not been tested; one aide had taken the CNA class twice without passing and needed special testing accommodation, while the other had completed NA training and was waiting for a test date.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Use of CNA Students as Independent Staff Without Completed Training and Competency Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides had completed a training and competency evaluation program or were appropriately enrolled and supervised prior to working independently. Surveyors reviewed the resident roster showing 58 residents in the building and examined nursing and CNA schedules for the prior two weeks, which showed CNA students assigned their own halls on multiple dates. Staff interviews revealed that CNA students were being scheduled and counted as regular CNAs, assigned full hall responsibilities, and included in staffing numbers once they were “signed off” on certain skills, despite not having completed CNA certification or state testing. The facility’s DON acknowledged counting CNA students as independent staff members on the schedule once their skills were signed off and avoiding scheduling them in memory care only because there was a single CNA there. CNA staff reported that students were frequently working as part of the regular staffing pattern, being given their own assignments without being paired with a CNA for training. One CNA stated that there were supposed to be four CNAs on the south end but that they were short staffed and that students who had not finished class or testing were being given hall assignments. Another CNA reported struggling to complete showers and answer call lights while working with students who were treated as fully capable staff. A CNA student confirmed being in the facility’s CNA course for 1–2 months, taking online classes with clinical hours twice weekly, but also picking up additional days that were no different from clinical days, and being independently assigned to a hall and additional rooms. The ADON and DON both indicated their understanding that once classroom work and skills sign-offs were completed, students could work their own assignments prior to certification, which conflicted with the requirement that nurse aides be trained and competent or appropriately enrolled and supervised within the first four months of employment.
Nurse Aide Worked Beyond Required Training Period Without Certification
Penalty
Summary
The facility did not ensure that a nurse aide who had worked more than 4 months had completed a training and competency evaluation program within the required timeframe. Record review showed that Nurse Aide 1 was hired on 5/19/25 and, as of the personnel file review on 4/13/26, there was no verification on file of a completed nurse aide competency and certification course. During interview, Human Resources stated that the nurse aide was given information on how to obtain certification and how to be reimbursed by the facility, and that the nurse aide had been working without certification since being hired in May 2025. Human Resources also stated that the nurse aide signed a form acknowledging the education and the requirement to obtain certification within 4 months of hire, but that form was not provided to the State Survey Agency. The Director of Nursing stated he was aware that the nurse aide had been working longer than 4 months without obtaining certification.
Failure to Verify Nurse Aide Certification Prior to Allowing Work
Penalty
Summary
The facility failed to ensure that a Pennsylvania Nurse Aide Registry check was obtained prior to allowing an agency nurse aide to work in the building. Facility policy, last revised July 7, 2023, required that all offers of employment be contingent upon a thorough criminal background check and verification that any required license or certification was active and in good standing. Despite this policy, one agency nurse aide (Employee E3) worked multiple shifts at the facility without the facility obtaining direct verification of her nurse aide certification status from the Pennsylvania Nurse Aide Registry. The deficiency was identified after the Pennsylvania Attorney General's Office notified the facility that the agency nurse aide did not possess a valid nurse aide certification during the time she provided services. The facility had relied on the staffing agency to obtain and verify the nurse aide’s credentials. The facility’s investigation file included an email from the staffing agency stating that the nurse aide had submitted a falsified license document that appeared legitimate, and that the agency’s onboarding team had been accepting uploaded licenses from clinicians rather than independently running verification checks. As a result, the unlicensed agency nurse aide worked several dates at the facility before being removed from the schedule.
Uncertified nurse aides worked beyond required timeframe
Penalty
Summary
The facility failed to ensure that nurse aides were certified within the required time frame for 2 of 5 nurse aides reviewed, NA C and NA D. Record review showed NA C had a hire date of 4/08/2024, worked full time, and had no evidence of nurse aide certification. NA D had a hire date of 03/21/2025, worked full time, and also had no evidence of nurse aide certification. The report states that both aides had worked in the facility longer than four months without being enrolled in or having completed an approved training course. During interview, the DON and ADON stated the expectation was for the facility to have certified nurse assistants. The ADON stated that both she and the DON were aware that NA C and NA D had not been tested. She stated there had been no certified applicants and the facility had only been able to hire NAs. She also stated that NA C had previously been terminated for not having CNA certification, had taken the CNA class twice without passing the test, and required special accommodation for testing. NA D had completed NA training on 06/25/2025 and was waiting on a test date. The facility policy titled The Role of the Hospitality Aide described duties for hospitality aides, including non-nursing, non-direct care duties under supervision of licensed nursing personnel.
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