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:
Failure to Verify LNA Licensure: The facility failed to follow up on an NA who was hired into an LNA role after completing a state-approved training and competency evaluation program. The employee file showed a provisional nursing assistant license with an expiration date, but there was no evidence the facility verified that the official license was obtained when the provisional license expired. The DON confirmed the NA had continued performing LNA duties without the required license.
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.
Failure to Verify NA Registry Before Hiring: The facility failed to ensure NA registry verifications were completed before four employees were allowed to work and provide care to residents. Employee files showed no documentation that the registry checks were completed before hire, despite the facility policy requiring HR to verify CNA certification status in the applicable state registry. HR stated she only checked nursing staff and was unaware that non-nursing staff also needed registry verification, while the Administrator and DON stated onboarding requirements should be completed upon hire.
Failure to Verify LNA Licensure
Penalty
Summary
The facility failed to follow up to ensure that 1 of 5 sampled staff members, an unlicensed Nursing Assistant who had been hired as a Licensed Nursing Assistant, obtained actual licensure within 4 months of passing a state-approved training and competency evaluation program. The employee file showed that the NA was hired by the facility and later changed to an LNA role, and she was granted a provisional nursing assistant license by the State Board of Nursing with an expiration date. There was no evidence in the file that the facility verified that she obtained her official license when the provisional license expired. The NA continued to be employed by the facility to perform LNA duties after the provisional license expired and before the official license was obtained. During interview, the DON confirmed that the NA had not obtained the nursing assistant license required to perform LNA duties and that the facility had not followed up to ensure that she did so.
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 Employment
Penalty
Summary
The facility failed to ensure Nurse Aide registry verifications were completed before allowing four employees to work and provide care to residents. Review of the facility’s Background Investigations policy showed that for applicants applying for a certified nurse aide position, Human Resources was to contact the nurse aide registry of the state in which the individual was certified and/or previously employed to verify that certification was in good standing. However, review of the employee files for Employees AAA, CCC, DDD, and EEE showed no documentation that NA registry verification had been checked before hire. Employee AAA had a date of hire of 6/24/25, Employee CCC had a date of hire of 3/13/26, Employee DDD had a date of hire of 4/3/26, and Employee EEE had a date of hire of 1/12/26. During interview, HR personnel stated she only checked nursing staff for NA registry verification and was not aware that non-nursing staff were supposed to be checked. She also stated that all four sampled employees’ NA registry verifications were checked during the survey after the DON made her aware. The Administrator and DON stated that onboarding requirements should be completed upon hire and that HR was responsible for ensuring NA registry verifications were checked for newly hired employees.
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