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
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure CNA A had current nurse aide certification and registry verification before and while working as a CNA. Record review showed the personnel file lacked documentation of an active certification, and time records showed CNA A worked a full shift while the status was expired. Interviews with the DON, HR, and CNA A confirmed that verification and monitoring were handled through TULIP, that leadership had been told the license was expired, and that CNA A was still providing care despite not realizing the certification had lapsed.
CNA Worked Without Current Certification: The facility failed to ensure a CNA had a current, active certification before working. Registry review showed the CNA record was not found and the certification had expired, yet the employee was listed as a full-time CNA, had an offer letter for CNA work, and worked multiple months in the Nursing Dept. HR confirmed the CNA was onboarded despite the invalid license and remained employed in the CNA role.
Failure to Verify LNA Licensure: The facility failed to follow up on an NA who was hired into an LNA role after completing a state-approved training and competency evaluation program. The employee file showed a provisional nursing assistant license with an expiration date, but there was no evidence the facility verified that the official license was obtained when the provisional license expired. The DON confirmed the NA had continued performing LNA duties without the required license.
The facility failed to ensure CNA C had current NAR verification before working resident care shifts. Records showed CNA C’s NAR had expired, yet she worked multiple overnight shifts after expiration. CNA C said she knew it was expired and had asked the HR Coordinator for help renewing it through TULIP, while the HR Coordinator and HR Manager acknowledged the lapse. Facility policy required current credentials before work and ongoing verification of employee credentials.
A facility failed to ensure that agency staff 10, who provided nurse aide services, was listed on the state nurse aide registry before working in the facility for a facility-reported staff-to-resident abuse allegation. The Administrator confirmed the staff member did not meet CNA competency or certification requirements and had only received on-the-job caregiver training, and the DON agreed the registry should be verified before hiring staff.
Missing Nurse Aide Registry Verification Records: The facility failed to verify nurse aide competency and maintain registry verification records for 12 sampled nurse aides before allowing them to care for residents. The DON/Administrator reported that staff files were disorganized, the registry records were usually kept in a binder in HR but could not be located, and verification was not provided for one nurse aide while records for the others were later produced.
Missing Current CNA Registry Verification
Penalty
Summary
The facility failed to ensure it received registry verification for 1 of 5 employees reviewed before allowing CNA A to serve as a nurse aide. Record review showed CNA A had a date of hire and a TULIP employability status check indicating the NAR status would expire on a later date, but the personnel file did not contain documentation showing a current nurse aide certification while CNA A was employed and actively providing care for residents. The file also did not contain any disciplinary action forms related to resident care concerns. Time punch records showed CNA A worked a full shift on the date reviewed. During interviews, the DON stated HR was responsible for verification and monitoring of staff licensures and that verifications were completed at the hospital next to the facility. HR stated verifications were run through TULIP and communicated to facility leadership, and that she had informed the ADON two weeks earlier that CNA A's license had expired. CNA A stated she had worked for the facility for 4 years, was not aware the license was expired, and had worked a recent day shift. The DON also stated the ADON was on vacation, and the facility did not provide the requested policy for credentialing nursing services personnel.
CNA Worked Without Current Certification
Penalty
Summary
The facility failed to assure that all Certified Nursing Aides had a current, active certification before working in the facility for 1 of 7 employees sampled. Review of the Iowa Single Contact Repository result for Staff L showed a record not found, and the Iowa Nursing Aide Registry showed the CNA certification status as no employment, with a certification date of 10/22/2020 and an expiration date of 10/22/22. The facility’s Active Employee Report listed Staff L as a full-time CNA in the Nursing Department, and the facility also provided an offer of employment letter showing an anticipated first day of employment of 2/27/26. A timecard detail report showed Staff L worked at the facility during March, April, May, June, and July 2026. During interview, Human Resources stated the facility completed onboarding with Staff L and gave an offer letter, but the SING had already been run and showed the CNA license was not valid. Human Resources stated Staff L did work after those dates as a CNA and was currently employed as a CNA at the facility. The Administrator stated she would expect all CNAs and nursing staff to have current certifications or licenses while working at the facility.
Failure to Verify LNA Licensure
Penalty
Summary
The facility failed to follow up to ensure that 1 of 5 sampled staff members, an unlicensed Nursing Assistant who had been hired as a Licensed Nursing Assistant, obtained actual licensure within 4 months of passing a state-approved training and competency evaluation program. The employee file showed that the NA was hired by the facility and later changed to an LNA role, and she was granted a provisional nursing assistant license by the State Board of Nursing with an expiration date. There was no evidence in the file that the facility verified that she obtained her official license when the provisional license expired. The NA continued to be employed by the facility to perform LNA duties after the provisional license expired and before the official license was obtained. During interview, the DON confirmed that the NA had not obtained the nursing assistant license required to perform LNA duties and that the facility had not followed up to ensure that she did so.
Expired CNA Registry Verification
Penalty
Summary
The facility failed to ensure registry verification showed that CNA C met competency requirements before providing care to residents. Record review showed CNA C had a date of hire listed in the personnel file, and the last Employability Status Check Search showed CNA C’s NAR status had expired. Employee time clock records showed CNA C worked multiple overnight shifts after the expiration date, including several 6:00 p.m. to 6:00 a.m. shifts. During interviews, CNA C stated she knew her NAR status had expired and that she had told the HR Coordinator she needed help renewing it through TULIP. The HR Coordinator stated he was not aware the status was expired, though he knew it was close to expiring and had missed helping her on prior occasions. The HR Manager confirmed CNA C’s NAR was expired and stated she had been instructed to renew it herself, with his help. The HR Coordinator, DON, and Corporate Quality Assurance Nurse all stated that EMR/NAR checks were supposed to be completed upon hire and annually, and the facility policy required current credentials before beginning work and throughout employment.
Failure to Verify Nurse Aide Registry Status Before Use
Penalty
Summary
The facility failed to ensure that agency staff 10, who was providing nurse aide services, was listed on the state nurse aide registry before working in the facility for one of three facility-reported staff-to-resident abuse allegations reviewed (Intake #2659390). During an interview on 05/21/26 at 11:12 AM, the Administrator confirmed that AS10 did not meet competency evaluation requirements and did not have a nurse aide certification. The Administrator also stated that AS10 had received on-the-job training as a caregiver but would not be appropriate for the Long-Term Care program, and agreed that AS10 should not have worked in LTC. During an interview on 05/21/26 at 09:19 AM, the DON confirmed that the facility should verify the nurse aide registry prior to hiring staff and agreed with that expectation.
Missing Nurse Aide Registry Verification Records
Penalty
Summary
The facility failed to implement a policy and procedure to obtain verification from the Washington State Nurse Aide Registry and/or Multi-State Nurse Aide Registry to ensure nurse aide staff met competency evaluation requirements for 12 of 12 sampled nurse aide staff: Staff E, F, I, K, L, M, Q, R, S, T, U, and V. The report states that the failure involved allowing nurse aide staff to care for residents without verifying competency and without maintaining registry verification records prior to resident care. During interview, the Administrator stated that staff files were not organized and registry verification records were not readily available. The Administrator also stated that a corporate human resources representative had completed an audit a few months earlier and that corporate staff had completed all new hire verifications since that audit, but the registry verification records were usually kept in a binder in the human resources office and could not be located. Registry verification was provided for Staff E, I, K, L, M, Q, R, S, T, U, and V, but not for Staff F, and the Administrator stated the records should be available for state agency review but were not.
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