Uncertified Nursing Assistants Providing Care
Summary
The facility failed to ensure that three nursing assistants, identified as NA A, NA B, and NA C, completed their state certification program, including the necessary examination to test their knowledge and skills. This resulted in these individuals working as Certified Nurse Assistants (CNAs) without proper certification, which could potentially compromise resident safety. The California Department of Public Health Licensing and Certification Verification Search Page confirmed that these nursing assistants did not have active CNA certifications. NA A was hired with the expectation of obtaining certification, as indicated in her hire letter and job description, but she had been working for six months without completing the certification process. Similarly, NA B and NA C were hired under the same conditions but had not yet taken the required skills and written tests. Despite this, they were assigned to care for residents independently, as evidenced by the facility's staffing schedules and sign-in sheets. Interviews with the nursing assistants revealed that they were aware of their uncertified status, yet they continued to perform duties typically assigned to certified CNAs. The facility administrator confirmed that these nursing assistants were providing care without having completed the necessary certification tests, acknowledging that this should not have occurred. According to the Healthcare Professional Certification Program, individuals can only work as nursing assistants for up to 120 days while certification requirements are pending, which was not adhered to in this case.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A nursing assistant who had completed CNA coursework but had not passed the state certification test was allowed to work as a CNA for longer than the four months permitted for uncertified aides. Human Resources confirmed the staff member continued working past the allowed period, resulting in non-compliance with staff qualification requirements and potentially affecting all residents.
The facility failed to ensure nursing assistants received required training before providing direct care, affecting all 46 residents. A nurse aide in training performed duties without formal training, and several nursing assistants were hired without being on the nurse aide registry or enrolled in training programs. The facility believed they had four months to enroll aides in classes, but some worked longer without enrollment.
Unqualified Nursing Assistant Worked Beyond Permitted Timeframe
Penalty
Summary
The facility failed to ensure that a nursing assistant was properly qualified to provide resident care, as required by regulations. Record review showed that a nursing assistant was hired after completing a CNA course but had not passed the state certification test. Despite this, the staff member worked as a CNA for a period exceeding the four months allowed for individuals who have not yet obtained certification. Human Resources confirmed that the nursing assistant continued to work past the permitted timeframe without having passed the state test, resulting in non-compliance with staffing qualification requirements. This issue had the potential to affect all 142 residents in the facility, as the staff member was involved in direct resident care.
Failure to Ensure Proper Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that nursing assistants received the required training before providing direct care to residents, potentially affecting all 46 residents. Employee #145, a nurse aide in training, had not started formal training classes but was performing duties equivalent to a state-tested nursing assistant, including helping with meals, providing showers, and incontinence care. Despite having previous experience in a group home, Employee #145 had not received dementia training or training on handling aggressive behaviors. The Human Resource employee confirmed that Employee #145 was not enrolled in classes and was functioning as a state-tested nursing assistant based on the Administrator's instructions. Additionally, the facility hired several nursing assistants who were not on the nurse aide registry at the time of hire and were not enrolled in nurse aide registry classes or nursing school. These employees, including STNA #155, STNA #120, and STNA #110, had their skills checked off on orientation checklists despite not being registered or enrolled in training programs. The Human Resource employee verified that the facility believed they had four months to enroll aides in classes, and some employees had worked longer than four months without being enrolled in the NATCEP program, as the Administrator decided the timing of enrollment.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
