Uncertified Staff Member Performed Resident Care Duties
Summary
A deficiency was identified when a staff member assigned as a "Monitor" was found performing resident care activities, specifically Activities of Daily Living (ADLs), for a resident. The staff member, referred to as Monitor #1, did not possess a Certified Nurse Aide (CNA) license, as confirmed by a review of her personnel file and her own admission during an interview. Monitor #1 stated that she had attended CNA school and had taken the certification test but failed. Despite this, she reported performing tasks such as changing and caring for residents, which are duties reserved for certified and competent nurse aides. Further investigation revealed that facility leadership, including the Director of Nursing and other administrative staff, were not aware that Monitor #1 was providing direct resident care. The facility's job description for the "Monitor" position did not include providing resident care, but rather focused on supervision, assistance with transportation, and support during mealtimes and leisure activities. The facility was unable to provide an assignment sheet for the relevant date, and interviews confirmed that the Monitor was not authorized to perform CNA responsibilities. The resident involved had a history of cognitive impairment and required significant assistance with daily activities.
Plan Of Correction
F728 Hiring/Use of Nurse Aides 1. Corrective Action - On 4/10/25, monitor #1 received an education and disciplinary action for failure to adhere to their job description. - On [R], monitor #1 was terminated and is no longer employed at the facility. - On 4/10/25, HR Director audited all nursing assistant files to assure they are within their 120 days based on regulatory requirement. All nursing assistants (total of 11) met regulatory criteria for employment as nursing assistants. - On 4/10/25, HR Director audited all nursing assistants to ensure compliance with job description and scope of practice. - On 4/10/25, HR Director educated all monitors (9) on their job description. - On 4/10/25, HR Director audited all monitors' employee files for signed job description and not providing direct care to residents. 2. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measures Put Into Place: - HR Director and/or designee will audit monthly X6 months all nursing assistants to ensure that they do not work more than 120 days. - Director of Nursing/designee will audit the monitors' performance to assure it is compliant with their job description weekly X4 weeks and then monthly X6 months. 4. How Will These Actions Be Measured: - The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. - Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. - The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to ensure an agency staff member who was a full-time employee completed the required nurse aide training and competency evaluation program within 4 months of hire. Record review showed no start date, license number, or expiration date for the aide, and the Administrator confirmed the aide was not certified, had only on-the-job caregiver training, and should not have worked in the LTC program.
Nurse aide certification oversight failed when a full-time NA continued providing direct resident care without completing the required training and competency evaluation within the required timeframe. The DON, LVN, and ADMN stated the aide had been allowed to work after failing the skills test, while the facility’s policy and job description required competency and certification within four months of employment.
The facility failed to verify a newly hired CMA's certification before hire. The New Hire List and Roster listed the CMA as hired, but there was no documentation of certification verification. The facility policy stated that all personnel certifications would be verified, and the DON stated that CNA verification and criminal background checks should be done before hire.
Facility staff failed to ensure five NAs completed the required CNA training program within 120 days of hire. Personnel files lacked documentation of completion, and interviews showed some aides were still working on the floor assisting residents while they were awaiting written or skills testing, had not scheduled testing, or had failed the written exam. The ADON and administrator acknowledged the aides were still being scheduled to assist with resident care despite not being certified.
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.
Uncertified Nurse Aide Worked Without Required Competency Evaluation
Penalty
Summary
The facility failed to ensure that agency staff 10, identified as a full-time employee, completed the required nurse aide training and competency evaluation program or a State-approved competency evaluation program within four months of hire. During record review, the facility document titled "Agency Staff Checklist for Credentials" showed no specific start date for NA10, and the certification information did not include a license number or expiration date, indicating the individual was not certified. In interview, the Administrator confirmed that AS10 did not meet competency evaluation requirements or have nurse aide certification, stated that AS10 received on-the-job training for caregiver duties but would not be appropriate for the facility's LTC program, and acknowledged that AS10 should not have worked in the LTC facility. The facility's CNA job description also stated that staff must have current CPR and Hawaii CNA certification.
Nurse Aide Not Certified Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a full-time nurse aide was certified within four months of hire. Record review showed NA C was hired on 10/29/2025 as a full-time nurse aide and began working on the floor providing resident care on 11/3/2025. During interviews, NA C stated she had completed an online course before hire, passed the written test at the end of March 2026, failed the skills test on 4/21/2026, and was scheduled to retake it on 5/26/2026. The DON stated NA C had been working as a full-time nurse aide and was taken off the schedule on the day of the survey. Interviews with LVN D, the DON, and the ADMN showed the facility allowed NA C to continue providing direct resident care after failing the clinical skills test. LVN D stated the facility performed its own skills checkoff and allowed nurse aides to provide showers, incontinent care, feeding assistance, and other direct care independently, though they could not use the mechanical lift. The DON stated LVN D was responsible for making sure nurse aides were certified, and the ADMN stated her expectation was that nurse aides complete training and the CNA test within 180 days of working full-time; if the clinical test was failed, they should be moved to hospitality aid until they passed. The facility policy required nurse aides to demonstrate competency in skills and techniques necessary to care for residents' needs, and the job description stated nurse aides must be certified or complete state-required training and competency evaluation within four months of employment.
Failure to Verify CMA Certification Before Hire
Penalty
Summary
The facility failed to verify the validity of a Certified Medication Assistant (CMA) certification before hire for 1 of 1 newly hired CMAs. The undated New Hire List and Roster listed Staff J, CMA, with a hire date of 8/14/25, but the facility lacked documentation showing verification of Staff J's CMA certification. The facility policy titled License Verification, revised in 2025, stated that the facility would verify all personnel certifications. During interview on 5/7/26 at 11:36 a.m., the DON stated that CNA verification and criminal background checks should be completed before hire.
Nurse Aides Not Certified Within Required Timeframe
Penalty
Summary
Facility staff failed to ensure five nurse aides completed the nurse aide training program within 120 days of employment in the facility. The facility census was 91.1, and review of the facility policies showed no policy was provided for nurse aide training and requirements. The job description for Certified Nursing Assistant showed the minimum qualification was to be licensed as a CNA in accordance with state requirements. Review of personnel files showed NA C, NA D, NA E, NA F, and NA G each had a hire date and later began working as nurse aides, but none of the files contained documentation that they completed the nurse aide training program. Interviews with the ADON and the nurse aides showed several were still working on the floor assisting residents while they were not yet certified, some had completed classwork but had not completed required testing, and others had failed written testing or had no skills test scheduled. The administrator stated nurse aides should be certified within 120 days of hire and acknowledged the five nurse aides were still scheduled to work the floor to assist with resident care.
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.
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