Unlicensed admissions director provided incontinence care
Summary
The facility failed to ensure incontinence care was provided to one resident by licensed staff. Resident #45 was admitted with diagnoses including a sacrum pressure ulcer, congestive heart failure, stroke, and chronic kidney disease. The most recent MDS indicated the resident had a BIMS score of 5, showing severe cognitive impairment, and that the resident was incontinent of both bowel and bladder and dependent on staff for incontinence care. During observation, the surveyor saw two staff members providing incontinence care to Resident #45, including one person dressed in business casual attire. That staff member identified herself as the admissions director and also said she was a CNA. The Administrator stated she was not licensed as a CNA and should not have been providing direct care. The admissions director later said her CNA license expired in 2022, she had not renewed it, and she had not received facility education on providing incontinence care.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure CNA C had current NAR verification before working resident care shifts. Records showed CNA C’s NAR had expired, yet she worked multiple overnight shifts after expiration. CNA C said she knew it was expired and had asked the HR Coordinator for help renewing it through TULIP, while the HR Coordinator and HR Manager acknowledged the lapse. Facility policy required current credentials before work and ongoing verification of employee credentials.
A facility failed to ensure that agency staff 10, who provided nurse aide services, was listed on the state nurse aide registry before working in the facility for a facility-reported staff-to-resident abuse allegation. The Administrator confirmed the staff member did not meet CNA competency or certification requirements and had only received on-the-job caregiver training, and the DON agreed the registry should be verified before hiring staff.
Missing Nurse Aide Registry Verification Records: The facility failed to verify nurse aide competency and maintain registry verification records for 12 sampled nurse aides before allowing them to care for residents. The DON/Administrator reported that staff files were disorganized, the registry records were usually kept in a binder in HR but could not be located, and verification was not provided for one nurse aide while records for the others were later produced.
The facility failed to verify a NA on the state OBRA registry before employment. A NA was hired without documentation of registry verification, and the Staffing Coordinator said there was no record on the state registry. The DON stated the verification should have been completed before orientation and before the NA started work.
The facility failed to verify Nurse Aide Registry status before hiring or starting work for three employees, including CNAs and a CMA. Record review showed the registry checks were completed after hire and after New Employee Orientation, and the HR Director and Administrator stated they did not know the checks had to be done before date of hire or start of employment.
The facility failed to complete OBRA registry verification for 2 NAs before they worked in the facility. Their personnel records had no OBRA documentation, and HR and the Administrator confirmed the required verification process was not followed despite the facility abuse prohibition policy and state guidance requiring active registry status.
Expired CNA Registry Verification
Penalty
Summary
The facility failed to ensure registry verification showed that CNA C met competency requirements before providing care to residents. Record review showed CNA C had a date of hire listed in the personnel file, and the last Employability Status Check Search showed CNA C’s NAR status had expired. Employee time clock records showed CNA C worked multiple overnight shifts after the expiration date, including several 6:00 p.m. to 6:00 a.m. shifts. During interviews, CNA C stated she knew her NAR status had expired and that she had told the HR Coordinator she needed help renewing it through TULIP. The HR Coordinator stated he was not aware the status was expired, though he knew it was close to expiring and had missed helping her on prior occasions. The HR Manager confirmed CNA C’s NAR was expired and stated she had been instructed to renew it herself, with his help. The HR Coordinator, DON, and Corporate Quality Assurance Nurse all stated that EMR/NAR checks were supposed to be completed upon hire and annually, and the facility policy required current credentials before beginning work and throughout employment.
Failure to Verify Nurse Aide Registry Status Before Use
Penalty
Summary
The facility failed to ensure that agency staff 10, who was providing nurse aide services, was listed on the state nurse aide registry before working in the facility for one of three facility-reported staff-to-resident abuse allegations reviewed (Intake #2659390). During an interview on 05/21/26 at 11:12 AM, the Administrator confirmed that AS10 did not meet competency evaluation requirements and did not have a nurse aide certification. The Administrator also stated that AS10 had received on-the-job training as a caregiver but would not be appropriate for the Long-Term Care program, and agreed that AS10 should not have worked in LTC. During an interview on 05/21/26 at 09:19 AM, the DON confirmed that the facility should verify the nurse aide registry prior to hiring staff and agreed with that expectation.
Missing Nurse Aide Registry Verification Records
Penalty
Summary
The facility failed to implement a policy and procedure to obtain verification from the Washington State Nurse Aide Registry and/or Multi-State Nurse Aide Registry to ensure nurse aide staff met competency evaluation requirements for 12 of 12 sampled nurse aide staff: Staff E, F, I, K, L, M, Q, R, S, T, U, and V. The report states that the failure involved allowing nurse aide staff to care for residents without verifying competency and without maintaining registry verification records prior to resident care. During interview, the Administrator stated that staff files were not organized and registry verification records were not readily available. The Administrator also stated that a corporate human resources representative had completed an audit a few months earlier and that corporate staff had completed all new hire verifications since that audit, but the registry verification records were usually kept in a binder in the human resources office and could not be located. Registry verification was provided for Staff E, I, K, L, M, Q, R, S, T, U, and V, but not for Staff F, and the Administrator stated the records should be available for state agency review but were not.
Failure to Verify Nurse Aide Registry Status Before Employment
Penalty
Summary
The facility failed to ensure that a nursing assistant was verified on the state Nurse Aide Registry before starting employment. Staff D, a Nursing Assistant, was hired on 03/26/2026, and the personnel record did not contain documentation showing that the individual was on the OBRA registry as required. The deficiency was identified during record review of staff qualification and background information. During interviews, the Staffing Coordinator stated there was no record of Staff D on the state registry and that the issue was missed during some switching of positions at the facility. The Director of Nursing stated OBRA registry verification was completed before moving forward in the hiring process, but also stated the verification should have been completed before orientation and was unsure how the failure occurred. The DON further stated there should be a process in place to verify nursing assistant OBRA status before starting work.
Failure to Verify Nurse Aide Registry Before Hire
Penalty
Summary
The facility failed to obtain Nurse Aide Registry verification that three employees had met competency evaluation requirements before they worked in the facility as nurse aides or medication aides. Record review showed CNA B was hired on 02/27/2026 and attended New Employee Orientation that same day, but the Nurse Aide Registry search was not completed until 03/08/2026. MA C was hired on 02/18/2026 and attended New Employee Orientation on the same day, but the Nurse Aide Registry search was not completed until 02/19/2026. CNA D was rehired on 04/21/2026 and attended New Employee Orientation on 04/28/2026, but the Nurse Aide Registry search was not completed until 04/29/2026. During interview, the Human Resources Director stated that after interviews, the Administrator completed the criminal history search, then Human Resources set up the new employee's date of hire and New Employee Orientation. The Human Resources Director stated that the Nurse Aide Registry searches were conducted up to 24 hours after the employee's date of hire and that she did not realize the searches should be done prior to date of hire or start of employment. The Administrator stated she did not know there was a timeframe for completing the Nurse Aide Registry searches and acknowledged that the searches were done after the employees had attended New Employee Orientation. The facility policy required verifying with the Nurse Aid Registry for all non-licensed staff, including CNAs and CMAs, that the potential employee was not listed as ineligible for employment.
Failure to Verify NA Registry Status
Penalty
Summary
The facility failed to obtain OBRA registry verification for 2 of 3 nursing assistants reviewed for staff qualifications. Staff M was hired on 12/10/2025 and began work on 01/11/2026, and Staff N was hired on 10/29/2025 and began work on 12/14/2025. Their personnel records contained no documentation of OBRA registry verification, even though the facility policy titled Abuse Prohibition stated potential employees would be screened for a history of abuse, neglect, and mistreatment by checking the appropriate licensing boards and registries. Washington State Board of Nursing guidance stated that a NA must be active on the OBRA Registry to work in a skilled nursing facility or nursing home, and that the registry identifies individuals ineligible to work because of abuse, neglect, or misappropriation findings. During interview, Human Resources staff stated OBRA verification was required before any NA was hired but that the process was not followed for Staff M and Staff N. The Administrator also stated OBRA verification was to be completed for regulatory compliance and the facility abuse prohibition policy, and confirmed the process was not followed.
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