Failure to Verify State Certification and Background Checks for CNAs
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) were certified in the State of Arkansas and did not complete required background checks for two nurse aides. Review of employee files revealed that both CNAs were certified in Oklahoma, but there was no documentation of Arkansas certification, current abuse registry checks, or other background checks specific to Arkansas. Additionally, annual employment screening required by Oklahoma regulations was not documented for either CNA. Skills check-off documentation was only present for one CNA, and neither file contained evidence of Arkansas-specific qualifications or screenings. Interviews with the CNAs confirmed that they were unsure of their certification status in Arkansas and relied on their Oklahoma credentials. One CNA was unfamiliar with Enhanced Barrier Precautions and could not clearly articulate infection control procedures. Facility policies and job descriptions required state-approved training and certification, but the documentation and interviews indicated these requirements were not met for the two CNAs reviewed.
Penalty
Resources
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The facility failed to ensure that a CNA providing personal care was properly certified with the State of Ohio. A staff member originally hired as a housekeeper completed an online NATCEP but never took the state certification exam, and there was no CNA license listed for this individual on the Ohio Nurse Aide Registry. Despite this, the staff member worked multiple 12-hour shifts providing direct care. The DON and HR later acknowledged they were unaware the state test had not been completed and that required follow-up on certification status did not occur, affecting all residents in the facility.
A CNA who had completed a training program but was not yet listed on the state nurse aide registry was observed providing morning care, including dressing and wheelchair positioning, to a resident. Personnel and state registry checks showed no proof of active certification, and staffing records confirmed the CNA had been scheduled and worked in the CNA role beyond the allowable grace period for non-registered aides. The CNA reported she was working as a CNA and providing resident care, and the Administrator acknowledged she had failed her first registry exam and should not have been working in a CNA capacity without passing the required competency test, contrary to facility policy requiring valid certification for such positions.
A CNA continued to work multiple shifts without a current and active registration after her renewal information was not re-entered into the system following a rescinded resignation. Human Resources failed to ensure her registration was renewed, and facility policy requiring removal from the schedule for expired credentials was not followed.
A facility employed an STNA without proper Ohio certification, affecting 77 residents. The STNA worked multiple shifts with an expired out-of-state certificate, contrary to facility policy requiring state-approved training and certification within four months of hire.
The facility failed to provide timely employment verification for STNAs, resulting in their registry status being changed to expired. This was confirmed through a review of staff schedules, the nurse aide registry, and interviews. The Administrator acknowledged the delay in submitting employment verifications, potentially affecting all 150 residents.
Unlicensed CNA Allowed to Provide Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that employed CNAs were properly certified with the State of Ohio, as required by facility policy and state regulations. Personnel record review showed that CNA #13 was originally hired as a housekeeper and later completed an online Nurse Aide Competency Evaluation Program (NATCEP), but there was no evidence she had obtained state certification. Timecard review for February 2026 showed CNA #13 worked multiple 12-hour shifts providing care. Review of the Ohio Nurse Aide Registry confirmed there was no current or expired CNA license for CNA #13. The facility’s policy on required training and certification stated that nurse aides must have successfully completed a state-approved NATCEP and either be awaiting certification results or be enrolled in a state-approved NATCEP within the first four months of employment, with certification to be verified through the state registry. Interviews further confirmed that CNA #13 was not licensed and was nonetheless providing personal care to residents. The DON acknowledged that CNA #13 had completed an online CNA program but never took the state test for licensure and verified that she was not licensed as a CNA. CNA #13 herself confirmed she was not licensed, was providing personal care, and reported that her scheduled state test had been cancelled during a government shutdown, and that the DON and Human Resources were not aware she had not completed the state test. Human Resources staff confirmed CNA #13 was not licensed and stated they failed to follow up after her test was cancelled. The facility census at the time was 65 residents, and the failure to ensure proper CNA licensure had the ability to affect all residents.
Uncertified CNA Allowed to Provide Direct Resident Care Beyond Permitted Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nurse aide had obtained proper placement on the state nurse aide registry before working as a CNA. Observation showed that Certified Nursing Assistant (CNA) #101 was providing morning care to a resident, including dressing and positioning the resident in a wheelchair. Review of CNA #101’s personnel file showed a hire date of 08/22/25 and completion of a Nurse Aide Training and Competency Evaluation Program on 06/13/25, but there was no proof of state registry in the file. A check of the State of Ohio State Tested Nursing Assistant website also did not show evidence of registry for this individual. Further review of the staffing schedule confirmed that CNA #101 was scheduled and worked in the role of CNA on 01/27/26 and 01/28/26. During an interview, CNA #101 stated she was employed as a CNA and was caring for residents on the day of observation. In an interview, the Administrator confirmed that CNA #101 had been employed longer than four months since completion of her CNA program, had failed her first registry test, and was scheduled to retake it. The Administrator acknowledged that CNA #101 should not have been working as a CNA providing resident care without having passed the registry examination. The facility’s policy stated that positions requiring certification or licensing must maintain valid credentials, and failure to do so could result in termination and reporting to the licensing board.
CNA Worked Without Active Registration Due to HR Oversight
Penalty
Summary
A review of personnel files, the Ohio State Tested Nursing Aide Registry, staff interviews, and facility policy revealed that a Certified Nursing Assistant (CNA) was allowed to work without a current and active registration. The CNA's registry had expired, and she was not eligible to work as a state tested nursing assistant during the period in question. Despite this, the facility's staffing schedule showed that the CNA continued to work multiple shifts after her registration had lapsed. The lapse occurred after the CNA initially submitted her resignation, leading Human Resources to remove her renewal information from the system. When the CNA decided to remain employed, her renewal information was not re-entered, resulting in the expiration of her registration. Facility policy required removal from the work schedule and suspension without pay for employees with expired licensure or certification, but this was not followed, allowing the CNA to continue working without valid credentials. This deficiency had the potential to affect all residents in the facility.
Unlicensed STNA Employed Without Ohio Certification
Penalty
Summary
The facility failed to ensure that a State Tested Nursing Aide (STNA) was properly licensed with the State of Ohio, which had the potential to affect all 77 residents. A review of the personnel file for STNA #200 revealed that the aide was hired with an expired nursing assistant registration from another state and had no current or expired licensure in Ohio. Despite this, STNA #200 worked multiple shifts, as evidenced by the clock in/out report, without the necessary certification. An interview with the Administrator confirmed that STNA #200 was employed and providing care to residents without being certified with the State of Ohio Nurse Aide Registry. The facility's policy requires that nurse aides must have completed a State-approved nurse aide training or competency evaluation program and provide documentation of certification within four months of hire. However, STNA #200 did not meet these requirements, as they were not certified in Ohio and had an expired out-of-state certificate.
Failure to Provide Timely Employment Verification for STNAs
Penalty
Summary
The facility failed to provide timely employment verification for State tested Nurse Aides (STNAs) #400 and #403, which resulted in their status on the nurse aide registry being changed to expired. This deficiency was identified through a review of staff schedules, the nurse aide registry, employment verification letters, and staff interviews. The review revealed that no evidence of employment had been provided for these STNAs within a 24-month period. An interview with the Administrator confirmed that the facility had not submitted the necessary employment verifications until after the expiration of their registry status. This deficiency had the potential to affect all 150 residents in the facility and was investigated under Complaint Number OH00156057.
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