Staff Licensing and Registration Deficiency
Summary
The facility failed to ensure that staff were licensed and registered in accordance with State laws for three of the eleven personnel files reviewed. Employee E21, a registered nurse, was found to be working with an expired nursing license, which had expired on October 31, 2024. The facility discovered this lapse on December 18, 2024, and subsequently provided education to Employee E21 regarding the policy that mandates maintaining an active nursing license at all times. Employee E21 reactivated her nursing license on December 20, 2024. Additionally, the facility conducted an audit of all employees with nursing licenses and nurse aide registries, which revealed that Employees E17 and E16, both nurse aides, were not included in the audit. Further review showed that neither employee was enrolled in the Pennsylvania nurse aide registry, a requirement for employment in a nursing care facility receiving Medicare or Medicaid reimbursement. Employee E17 was hired on October 22, 2024, and Employee E16 on November 19, 2024, both having completed a nurse aide training course prior to their hiring. However, they were not registered to work as nurse aides in Pennsylvania, as confirmed by the Nursing Home Administrator.
Plan Of Correction
1. Employee E21 provided no direct care and caused no harm to residents. Employee E17 and E16 are no longer employed at the facility. 2. Employee E21 was educated on his responsibility to ensure his license is renewed timely and active. 3. NPE or designee to educate licensed nursing staff on the importance of timely license renewal. 4. NPE or designee will conduct an initial audit of licensed nursing staff then monthly audits x 3 months to ensure compliance. 5. NHA or designee to review results of these audits at the monthly QAPI meeting x 3 months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN-level nursing supervisor worked a shift after the nurse's license had expired, and the DON confirmed the nurse provided care without a valid license.
Failure to verify RN license upon hire for an as-needed RN. HR stated the license check was missed when the nurse was hired, and corporate later notified the facility that the individual did not have RN licensure. The personnel file contained no RN license, and the Administrator stated HR should have verified the license at hire.
An LVN worked with an expired license after the facility failed to properly verify her credential status. The DON was unaware of the expired license, and the Administrator said the issue was found during an audit of licensed nurses. HR stated license checks were done on hire and annually, but the report used did not fully show the expiration date. The LVN said she did not know her license had expired.
Expired Nursing License: The facility failed to ensure an LVN maintained an active license while working as a nurse. Record review showed the LVN worked multiple shifts during the review period, and the BOM stated the LVN was later sent home after the facility found the license had expired. The BOM and ADM stated the BOM was responsible for checking nursing staff licenses, and the facility policy required current licensure verification and recertification before expiration.
A nurse was hired and worked as an RN for an extended period without a valid Arizona RN license after HR verified the wrong individual’s license based on a similar name and did not obtain a copy of the actual license. The nurse functioned as a floor RN, passing meds and assessing residents, while only holding an RN license from a non-compact state and awaiting Arizona endorsement. AZBN later informed HR that the nurse did not have an active Arizona license and should not be working as an RN, but the nurse continued to be scheduled for several days after this notification. The Administrator and DON initially believed or assumed the out-of-state license allowed practice, and only later confirmed that the other state was not part of the Nurse Licensure Compact, contrary to facility policy requiring verification and documentation of valid licensure before staff work in licensed roles.
The facility failed to ensure that an LN maintained a valid, active nursing license while providing care. One LN’s license had lapsed, as confirmed through Nursys and the state board verification system, yet the LN continued working for an extended period. Interviews with administrative and nursing leadership revealed that HR was responsible for license verification and tracking expirations, but due to multiple HR staff turnovers, required checks of nursing licenses and the nurse aide registry had not been kept current, contrary to the facility’s own background screening policy.
Unlicensed Nursing Supervisor Worked a Shift
Penalty
Summary
The facility did not ensure that one member of the nursing staff was appropriately licensed while providing care to residents. Review of facility documentation showed that Employee E3 worked as a nursing supervisor from 7:00 a.m. until 12:00 a.m. on one reviewed day, and further review showed that E3's nursing license had expired before that shift. An interview with the Director of Nursing confirmed that Employee E3 worked without a valid nursing license on that day.
Failure to Verify RN License at Hire
Penalty
Summary
The facility failed to verify the license qualification of a registered professional nurse upon hire for 1 of 3 licensed professionals reviewed, identified as V4. V3, the Director of Human Resources, stated that V4 was hired in August 2025 as an as-needed staff nurse and that it was an oversight on her part not to properly verify V4's RN license at the time of hire. In March 2026, V3 and facility administration were notified by the corporate office that V4 did not have the license qualification as a registered nurse. V1, the Administrator, stated that V3 should have ensured the nursing license was checked and verified upon hire. Review of V4's personnel record showed no RN license on file, and the health care worker registry dated 8/13/25 listed work eligibility as eligible.
Expired LVN License Not Identified
Penalty
Summary
The facility failed to ensure that one of six licensed staff reviewed, LVN B, maintained an active nurse license in accordance with state law. Record review showed LVN B was hired at the facility and that a Texas Board of Nursing verification checked by the facility showed her license had expired. A daily staffing assignment/sign-in log also showed LVN B worked on a day after the license expiration was identified in the record review. During interviews, the DON said she was not aware LVN B had an expired nurse license. The Administrator said she learned of the expired license during an audit of licensed nurses and stated LVN B was immediately removed from the schedule. HR said license checks were done on hire and annually, but the last check of licensed staff was completed in [DATE] and LVN B's expiration was missed because the report was not fully reviewed to see the expiration date. LVN B said she did not know her license had expired and stated she had last renewed it in [DATE]. The facility policy on credentialing nursing service personnel required staff who provide resident care or treatment within the scope of their license or certification to present verification of such license.
Expired Nursing License
Penalty
Summary
The facility failed to maintain sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 5 nursing staff reviewed, LVN C. Record review showed LVN C had an LVN/LPN license with an expiration date listed in the employee record, and the facility's punch-detail report showed LVN C worked multiple shifts over the reviewed period, including 11.1 hours, 11.08 hours, 11.93 hours, 11.17 hours, 12.07 hours, 9.07 hours, 5.0 hours, 10.92 hours, 3.03 hours, and 12.82 hours. During interview, the BOM stated she had checked LVN C's license and the expiration date was correct, but also stated LVN C was sent home the day before the interview when the facility checked her license and found it was expired. The BOM stated it was her responsibility to check nursing staff licenses and certificates, that she checked licenses upon hire, and that she had been trained to do so. The ADM stated the BOM was responsible for checking nursing staff licenses/certificates and expected all licensed individuals to be up to date when required. The facility policy required employees who need a license, certification, or registration to present verification prior to or upon employment and to provide recertification before expiration.
Unlicensed RN Allowed to Work Due to Faulty License Verification
Penalty
Summary
The facility failed to ensure that a licensed nursing staff member possessed a valid Arizona RN license during the entire period of her employment as an RN. The staff member applied for employment in March 2025 and indicated on her application that she held a valid RN license, with a handwritten note that she was to be endorsed upon arrival. A license verification report dated March 31, 2025, in her personnel file showed an active, unencumbered RN license for a different individual with the same first and last name but a different middle initial. There was no evidence in the personnel file of a valid Arizona RN license or any other state license verification belonging to this staff member, despite her being hired and classified as an RN. Staffing and payroll records showed that the staff member worked as a floor RN from mid-April 2025 until mid-February 2026, passing medications and assessing and caring for residents. A CNA reported that this RN functioned as a floor nurse, and that floor nurses are responsible for assessing residents when notified of changes in condition. The Arizona State Board of Nursing (AZBN) confirmed that the staff member had only been an RN license applicant by endorsement in Arizona and that she was considered foreign-educated, requiring additional steps such as language proficiency testing and third-party education verification. The AZBN stated that the staff member never held an Arizona RN license until April 6, 2026, and that she had been working at the facility as an RN without Arizona licensure or endorsement. The AZBN notified the facility’s HR Director on February 4, 2026, that the staff member did not have an active Arizona RN license and should not be working as an RN. The HR Director acknowledged that she was responsible for obtaining onboarding documents and verifying licenses via an online portal, and that the process did not include requesting a copy of the nursing license. She recognized that the verification in the file belonged to a different person and described this as an oversight. Despite the AZBN notification, payroll records showed that the staff member continued to work until February 11, 2026. The Administrator and DON both stated that they believed the staff member had an active license from another state and, at least initially, believed or assumed that this allowed her to practice, though the other state was not part of the Nurse Licensure Compact. The DON later confirmed via the compact website that the other state was not a compact state and that endorsement through Arizona was required. The facility’s written policy required verification of current, valid licensure and placement of license verification documents in the applicant’s file, which was not done correctly for this staff member, resulting in her working as an RN without a valid Arizona license for an extended period. The staff member herself stated that she first applied for an Arizona RN license sometime in 2024, did not receive it, then obtained an RN license from another state in March 2025 and subsequently applied for Arizona licensure by endorsement. She reported ongoing difficulties completing Arizona’s requirements, including language proficiency testing and education verification, while she was working at the facility. She stated that she believed she could work under her other state license and assumed it would be acceptable. She also reported that the HR Director had asked her shortly before the AZBN’s February 2026 call whether her Arizona license had arrived, and she replied that she was still working on the requirements. The Administrator later acknowledged that the license verification in the file was for another person and that, per facility policy, the staff member had not been qualified to work as an RN during the time she was employed in that role.
Failure to Ensure Licensed Nurse Maintained Active Nursing License
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed nurse maintained a valid, active nursing license while working. The facility had a census of 54 residents with a sample of 14 residents. Facility documentation dated 02/17/26 showed that an administrative staff member identified that one licensed nurse’s (LN H’s) nursing license had lapsed on 11/30/25. The facility verified the lapse through searches on the Nursys national nurse licensure database and the Kansas State Board of Nursing (KSBN) verification website. On 03/23/26, surveyors independently confirmed via Nursys and KSBN that LN H’s license had lapsed on 11/30/25, yet LN H continued to work at the facility with the lapsed license until 02/17/26. Administrative staff interviews revealed that human resources (HR) staff were responsible for verifying valid licenses and tracking expiration dates, but this process had not been maintained. An administrative nurse stated that recent turnover in HR staff contributed to nursing license and nurse aide registry checks not being kept up to date. Another administrative staff member reported that, after turnover of three different HR staff in the prior six months, she discovered that nursing license verifications had not been completed for some time. The facility’s Background Screening Investigations policy, dated November 2023, documented that for any licensed professional applying for a position involving direct resident contact, the respective licensing board is to be contacted to determine if any sanctions have been assessed against the applicant’s license.
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