Expired and Unverified CMA Gastrostomy Certifications During PEG Tube Medication Administration
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) held current advanced gastrostomy certifications before administering medications via gastrostomy (PEG) tubes. Record review showed that CMA #1’s advanced gastrostomy certification had expired, yet the October 2025 MAR for Resident #1 documented that CMA #1 administered medications through the resident’s PEG tube on multiple dates. The facility’s undated Medication Administration policy stated that medications are to be administered by licensed nurses or other staff legally authorized to do so in the state, in accordance with professional standards of practice. The DON identified that 24 residents in the facility received medications through PEG tubes. Further review revealed that CMA #2 and CMA #3 also lacked documented, current advanced gastrostomy certifications while administering PEG tube medications. CMA #2’s certification had expired, but October and November 2025 MARs for Resident #1 showed that CMA #2 administered medications through the PEG tube on several dates, and CMA #2 stated they were allowed to pass medications and perform feedings via PEG tube. CMA #3’s advanced gastrostomy certification was also not current, yet October, November, and December 2025 MARs for Resident #1 documented multiple instances of PEG tube medication administration by CMA #3. The DON initially stated that CMA #1 was the only CMA not certified to work the medication carts and later reported that CMA #2 and CMA #3 did have certifications, but they were not in the nurse aide registry and would be verified with the testing school. However, the facility did not provide documentation confirming current gastrostomy certification for CMA #2 and CMA #3 by the time of the survey.
Penalty
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Surveyors found that the facility failed to obtain and document an updated CNA registry verification before re-hiring a CNA who had previously been terminated. Review of the CNA’s personnel file showed an original registry check from the initial hire but no verification completed at the time of re-hire, and the administrator confirmed that no such documentation existed.
The facility failed to verify that an agency nurse aide had an active status on the Minnesota Nursing Assistant Registry before assigning her to a 7.5-hour day shift on a floor caring for multiple residents. The aide reported it was her first shift at the facility, and a registry search later showed her status had been inactive for over a year. The DON stated she relied on the staffing agency to send only registry-listed staff and acknowledged the facility did not verify active status for agency personnel, and the administrator confirmed that their process did not include checking current certification of agency aides. A requested facility policy related to this verification process was not provided.
The facility failed to ensure that one CNA had a completed initial competency evaluation upon hire. Record review showed the CNA was hired and the personnel file did not contain the required competency document, and the DSD confirmed the evaluation was not completed. Facility policy stated that competency validation is used to evaluate performance and that employees complete a competency skills assessment as part of the formal evaluation process.
A CNA worked an overnight 11 p.m. to 7 a.m. shift without an active CNA certification, in violation of federal nurse aide registry requirements and the facility’s job description requiring a valid CNA license. The DON had a personnel file printout indicating the CNA’s status was active and employable, but a concurrent CDPH registry search showed no matching data. Review of assignment and attendance sheets confirmed the CNA worked the shift after being called in by a Charge Nurse who did not realize the CNA had been removed from the schedule for lapsed certification. The DSD reported that CNAs with expired certifications are taken off the schedule and payroll and that this CNA had been informed of her limitations, yet she still worked the shift without valid certification.
Failure to Verify CNA Licensure at Hire: Facility staff failed to verify licensure at the time of hire for two CNAs reviewed. The HR Director said she was responsible for license verification and described a process involving review of a current license at interview, verification through the state department of health professions after management approval, and a second check by the employee’s manager after the CNA starts working with residents. The DON stated license verification at hire is important to confirm competency and prevent resident abuse.
Expired CNA Certification: The facility failed to ensure one CNA had a current and valid certificate on file. Record review showed the CNA's certification had expired, yet the CNA continued working on multiple scheduled shifts after expiration. The HR Director acknowledged the expired certification, and the Corporate Administrator stated the monthly certification check system missed the CNA.
Failure to Obtain CNA Registry Verification Prior to Re-Hire
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) registry verification was obtained prior to the re-hire of one CNA. Record review showed that this CNA had an initial hire date of 10/22/2012, a termination date of 04/19/2018, and a re-hire date of 10/10/2018. The personnel file contained a CNA registry verification dated 10/22/2012, corresponding to the original hire, but there was no documented evidence that a new CNA registry verification was obtained at the time of re-hire. During an interview on 03/18/2026 at 11:50 a.m., the administrator confirmed that the facility did not have documentation showing that a CNA registry verification was completed prior to re-hiring this CNA as required. This deficiency was identified for 1 of 2 CNA personnel records reviewed, specifically for the CNA who had a break in employment and was subsequently re-hired without updated registry verification documentation in the personnel record.
Failure to Verify Active Nurse Aide Registry Status for Agency Staff
Penalty
Summary
The facility failed to ensure that a nurse aide had a current competency evaluation on the Minnesota Nursing Assistant Registry before allowing her to work, affecting 1 of 1 nurse aides reviewed for registry verification and potentially all 71 residents. On 3/12/26 at 11:46 a.m., a nursing assistant (NA-A) reported it was her first shift at the facility, and the facility schedule for that date showed she was assigned to work a 7.5-hour day shift on the third floor, where 26 residents resided, with a total facility census of 71 residents. A Minnesota Nurse Aide Registry search, dated 3/13/26 at 11:45 a.m. and provided by the facility, showed NA-A’s registry status as inactive since 12/7/24. During interviews, the DON stated she trusted the staffing agency to send only staff who were on the registry and acknowledged the facility did not verify active status for agency staff, and the administrator confirmed that their process did not include verifying current certification of agency aides and that she expected only currently certified NAs would be sent. A facility policy related to this process was requested by surveyors but was not provided.
Missing CNA Competency Evaluation
Penalty
Summary
The facility failed to ensure that one of five sampled staff members, CNA 2, had a completed initial competency evaluation upon hire. During a concurrent interview and record review on 3/12/26 at 10:15 a.m. with the Director Staff Development, CNA 2's personnel file was reviewed and showed that CNA 2 was hired on 4/23/25, but there was no initial competency evaluation document in the file. The Director Staff Development stated that CNA 2's initial competency evaluation was not completed. The facility's Staff Competency Validation, dated 3/28/24, stated that competency validation is completed to evaluate an individual's performance, evaluate group performance, meet standards set by regulatory agencies, address problematic issues, and enhance performance review. The facility's policy and procedures titled Performance Review, dated May 23, 2019, stated that approximately two weeks prior to the evaluation, the employee will be given a copy of their job description, a performance evaluation form, and the competency skills assessment specific to their position, and the employee will complete the self-assessment portion of the Competency Skills Assessment.
CNA Allowed to Work Overnight Shift Without Active Certification
Penalty
Summary
Surveyors identified that one CNA worked an overnight 11 p.m. to 7 a.m. shift without an active CNA certification, contrary to federal nurse aide registry requirements and the facility’s own job description, which requires a valid CNA certification. During interview and record review with the DON, the CNA’s Licensing & Certification Verification Detail Page in the personnel file showed an active, employable status with a future expiration date, which the DON had relied upon. However, when the DON searched the California Department of Public Health (CDPH) website during the same review, no data was found for the CNA, confirming that the CNA did not have an active certification on the registry at the time she worked the shift. Further review of the nursing assignment and attendance sign‑in sheets for the overnight shift confirmed that the CNA had signed in and worked that shift. The DON stated that the situation occurred because the evening shift Charge Nurse, attempting to cover a CNA call‑off, contacted this CNA, who was known for helping cover shifts, and did not recognize that she had been removed from the schedule due to lapsed certification. In a separate telephone interview, the DSD explained that CNAs with lapsed certifications are removed from the monthly schedule and payroll until their certification is valid, and that this CNA had been informed of what she could and could not do with an expired certification. The DSD also noted that the CNA should have known her status when the system would not allow her to clock in, yet she knowingly worked the shift without a valid CNA certification.
Failure to Verify CNA Licensure at Hire
Penalty
Summary
Facility staff failed to verify licensure at the time of hire for two of three CNA records reviewed, CNA #10 and CNA #11. On 2/23/26 at 9:00 a.m., staff were asked to provide evidence that licensure had been verified at the time of hire for both CNAs. According to the Director of Human Resources, CNA #10 was hired on 5/13/25 and CNA #11 was hired on 10/10/25, but despite multiple requests, no evidence of license verification at the time of hire was provided. On 2/23/26 at 5:02 p.m., the Administrator and DON were informed of the concern. The DON stated that license verification at the time of hire is important to make sure staff members are competent and to prevent resident abuse. On 2/24/26 at 12:19 p.m., the Director of HR stated she was responsible for overall license verification and explained that the potential employee brings a copy of their current license at the initial interview, she verifies it through the state department of health professions after management approval, and the employee’s manager verifies it again after the employee starts working with residents. The facility’s abuse policy stated that the Business Office Coordinator/designee performs background checks prior to hiring and that the community must not employ individuals with certain abuse-related findings or disciplinary actions against their professional license.
Expired CNA Certification
Penalty
Summary
The facility failed to ensure that 1 of 15 CNA records reviewed had a current and valid certificate to work in the facility. Record review showed CNA 1's certification had expired, yet the staff schedule indicated CNA 1 continued to work on multiple days after the expiration date. During interview, the Human Resources Director stated CNA 1's certification had expired and that she was going to help her fix it. The Corporate Administrator stated there was a system in place to check certifications monthly, but CNA 1 was missed.
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