Failure to Ensure Nurse Aide Qualifications
Summary
The facility failed to ensure that two staff members, who were assigned nurse aide tasks, met the minimum qualifications for working as nurse aides. Staff #1 and Staff #2 were performing nurse aide tasks without having completed a state-approved training and competency evaluation program or being enrolled in such a program. Staff #1 was hired on October 23, 2024, and was scheduled to work 8-hour shifts performing nurse aide tasks from November 25 to November 28, 2024. She had moved to the US from another country where she was a certified nurse aide, but her certification was not recognized in North Carolina. She planned to take the CNA certification test but had not yet completed or enrolled in a state-approved program. Similarly, Staff #2 was hired on September 16, 2024, and was also scheduled to work 8-hour shifts performing nurse aide tasks during the same period. He had moved to the US from another country where he worked as a caregiver in a hospital. Although he was registered to begin a CNA certification program in December 2024, he had not completed or enrolled in a state-approved training and competency evaluation program. Interviews with the Business Administrator and the Director of Nursing revealed a misunderstanding of the regulatory requirements, as they believed that being in competency skills training at the facility was sufficient, and they were unaware that active participation in a state-approved program was required during the 4-month grace period.
Penalty
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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 allowed multiple nurse aides to work full time for more than four months without completing a state-approved nurse aide training and competency evaluation program or obtaining certification, as required. Staff interviews revealed that several aides had partially completed online or in-person CNA coursework, passed written exams, or finished computer-based training but had not passed skills or clinical components, and no testing or clinical arrangements were completed. The AIT confirmed that none of the involved nurse aides were certified and that a planned NATCEP at a sister facility had been cancelled, yet these aides continued to provide care beyond the four-month limit.
The facility allowed two nurse aides to provide direct resident care for longer than four months without obtaining CNA certification or documentation of listing on the Nurse Aide Registry. Both aides had completed a state-approved nurse aide training program and skills checkoffs and were working regular hours providing resident care, but their personnel files lacked proof of CNA status. The DON reported being unaware of the 120-day certification requirement, while the facility’s own policy limited non-certified aides to four months of employment while pursuing certification and required that they be on the path to registry listing.
The facility failed to ensure that nurse aides working more than four months were properly trained, competent, and certified within the required four-month timeframe. Two nurse aides were hired and worked full-time providing resident care, including incontinence care and bathing, before timely completion of the LTCR Nurse Aide Training and Competency Evaluation Program and without having taken or scheduled the CNA exam. The DON, Administrative Assistant, and Administrator each gave differing and incorrect timeframes for when aides must be certified, and the Administrative Assistant, who shared responsibility for tracking certification with the staffing coordinator, was unsure of the actual requirements. These practices conflicted with the facility’s written policy that prohibits using an aide for more than four months unless the aide has completed an approved training and competency evaluation program or has been deemed competent under federal regulations.
Surveyors found that caregiver hospitality aides were used as nurse aides for more than four months without completing a CNA training and competency evaluation program and without any competency check-offs. Two full-time hospitality aides, both uncertified, reported performing direct care tasks such as incontinent care and sit-to-stand transfers, sometimes without a CNA or nurse present. The DON and ADMN acknowledged that hospitality aides lacked competency checklists, were not supposed to provide hands-on care, and that staff providing direct care should be certified within four months of hire, but this had not occurred, creating potential for residents to receive improper care from individuals whose skills had not been validated.
The facility did not ensure that multiple full-time nurse aides obtained CNA certification or completed a state-approved training and competency evaluation program within four months of hire, as required by regulation and the facility’s own job description. Record reviews showed that several aides had been employed beyond four months with employability checks indicating no CNA certification, and interviews with the Office Manager and Administrator confirmed they were aware many aides were past the certification deadline. Leadership cited difficulty obtaining certification and recruiting CNAs in a rural area and noted they were awaiting or had just obtained approval to conduct a CNA class, while acknowledging ongoing noncompliance that could affect the appropriateness of care provided.
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.
Use of Uncertified Nurse Aides Beyond Four Months Without Completed Training and Competency Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides who worked more than four months were trained, competent, and had completed a state-approved nurse aide training and competency evaluation program (NATCEP) or competency evaluation, as required by 42 CFR §483.150(a) and (b). Review of employee files showed that multiple nurse aides (NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, and NA-L) were hired and worked full time for periods exceeding four months without being certified within the required timeframe. The facility’s own nurse aide job description required that nurse aides either have completed a state-approved training and competency evaluation program and hold a current state certificate, or be enrolled in an approved competency training program and perform only services for which they had demonstrated competence. Interviews with the involved nurse aides and the AIT confirmed that these staff members were not certified and had not completed all required components of the NATCEP. NA-A reported she had previously taken CNA classes and passed the written test but failed the skills test and never retook it. NA-C stated she had completed 40 hours of online CNA training and two in-person classes, but the facility stopped the CNA classes before she could complete certification. NA-F reported passing a written exam but failing the clinical exam and was waiting on additional training hours. NA-H stated she completed 60 hours of computer training but had not completed clinical hours due to lack of a site to complete that portion. The AIT acknowledged that none of the nurse aides were certified because they had not tested, and that a planned NATCEP at a sister facility had been cancelled. Despite these circumstances, the nurse aides continued to work full time beyond four months without the required certification or completed competency evaluation.
Use of Non-Certified Nurse Aides Beyond 4-Month Limit
Penalty
Summary
The facility failed to ensure that nurse aides who had worked more than four months were certified and competent, and that nurse aides who had worked less than four months were appropriately enrolled in training. One nurse aide (NA A) was hired as a nurse aide trainee on 03/01/25, completed the Texas Performance Nurse Aide Program training and skills checkoffs on 03/30/25, and began working regular hours on her hire date. As of 02/08/26, she remained employed and was observed providing resident care, but there was no documentation that she was a Certified Nurse Assistant or listed on the Nurse Aide Registry, despite having worked well beyond four months. Another nurse aide (NA B) was hired as a nurse aide trainee on 08/06/25, completed the Texas Performance Nurse Aide Program training and skills checkoffs on 01/30/26, and her timesheets showed she started working regular hours on 07/13/24. She was also observed providing resident care on 02/08/26, with no proof of CNA certification in her employee record. During an interview, the DON stated that NA A and NA B had completed their classes and competencies but were not yet certified and acknowledged not knowing that nurse aides needed to be certified within 120 days of hire. The facility’s undated policy stated that trained but non-certified nurse aides may work for up to four months while pursuing certification and must be on the path to being listed on the Nurse Aide Registry, but the records did not show that these requirements were met for NA A and NA B.
Failure to Ensure Nurse Aides Met Training and Certification Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides working more than four months were trained, competent, and certified within the required four-month timeframe, as required by OBRA and the facility’s own policy. Record review showed that NA D was hired on 01/03/2024 and completed the LTCR Nurse Aide Training and Competency Evaluation Program on 12/31/2024, indicating she worked full-time providing resident care such as incontinence care and bathing before timely completion of the program. NA B was hired on 11/12/2024 and completed the same training program on 02/16/2025, also working full-time and providing similar resident care during this period. Both aides reported they had not tested to become CNAs and did not have test dates scheduled. Interviews with facility leadership revealed confusion and incorrect understanding of the required certification timeframe. The DON stated that nurse aides had up to one year to get certified, while the Administrator stated that nurse aides had two years from completion of skills training to become certified. The Administrative Assistant, who along with the staffing coordinator was responsible for ensuring aides were certified within required timeframes, reported uncertainty about what those timeframes were and noted that the facility had been without a staffing coordinator until the day of the interview. These actions and inactions occurred despite a written facility policy stating that no individual would be used as a nurse aide for more than four months unless competent and having completed an approved training and competency evaluation program, or otherwise deemed competent under the federal requirements.
Uncertified Hospitality Aides Providing Direct Care Beyond 4 Months Without Competency Evaluation
Penalty
Summary
The deficiency involves the facility’s use of caregiver hospitality aides as nurse aides beyond four months of employment without completion of a nurse aide training and competency evaluation program, and without competency check-offs. Record review showed that one caregiver hospitality aide was hired on 08/06/2025 and another on 07/30/2025, both working full time, with employability status checks indicating neither had CNA certification. The facility’s job description for hospitality aides, dated 03/2020, listed a range of non-nursing, non-direct care duties under the supervision of licensed nursing personnel, but also included tasks such as providing personal care (e.g., combing hair, washing face and hands) and staying with residents while in the bathroom. During interviews, one caregiver hospitality aide reported performing incontinent care without a CNA or nurse at bedside and stated she had taken courses but had not taken the certification test. Another caregiver hospitality aide stated he performed sit-to-stand transfers with residents and, when the only CNA on night shift was busy, he would obtain help from another hospitality aide to perform incontinent care and transfers; he reported having been shown how to do these tasks at another facility but confirmed he was not certified. The DON stated that hospitality aides did not have competency check-off lists, were not supposed to perform peri-care or transfers, and were not to do anything involving touching residents because they were not certified. The DON and the administrator both acknowledged there were no competency check-off lists for caregiver hospitality aides, that uncertified staff were not supposed to provide direct care unless paired with a nurse or CNA, and that staff performing direct care should have certification within four months of hire, identifying this as a system failure between nurses and staff with potential for residents to receive improper care from uncertified aides.
Failure to Ensure Nurse Aide Certification and Competency Within Required Timeframe
Penalty
Summary
The facility failed to ensure that nurse aides working more than four months on a full-time basis were trained, competent, and had completed a state-approved training and competency evaluation program, as required. Record review showed that multiple nurse aides (NA-F, NA-I, NA-K, and NA-L) had been hired and working full time without obtaining CNA certification within four months of hire. Employability status checks for these aides, conducted months after their hire dates, documented that they had no CNA certification. The facility’s own job description for nurse aides required that they either have completed a state-approved training and competency evaluation program and hold a current state certificate, or be enrolled in an approved competency training program and perform only services for which they had demonstrated competence. During interviews, the Office Manager acknowledged that nurse aides were required to be certified within four months of hire and stated she was aware that many aides were past that deadline. She reported the facility was waiting for approval to conduct a nurse aide class. The Administrator also acknowledged awareness that many nurse aides were beyond the four-month deadline for certification, explaining that it was very hard to get people certified and difficult to find CNAs in a rural area. She stated the facility had just become certified to offer a CNA class but was uncertain whether the class could be held due to an Immediate Jeopardy that had been called and expressed uncertainty about how to proceed. The report notes that this failure could place residents at risk for receiving inappropriate care from individuals whose skill level was not known.
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