Uncertified Hospitality Aides Providing Direct Care Beyond 4 Months Without Competency Evaluation
Summary
The deficiency involves the facility’s use of caregiver hospitality aides as nurse aides beyond four months of employment without completion of a nurse aide training and competency evaluation program, and without competency check-offs. Record review showed that one caregiver hospitality aide was hired on 08/06/2025 and another on 07/30/2025, both working full time, with employability status checks indicating neither had CNA certification. The facility’s job description for hospitality aides, dated 03/2020, listed a range of non-nursing, non-direct care duties under the supervision of licensed nursing personnel, but also included tasks such as providing personal care (e.g., combing hair, washing face and hands) and staying with residents while in the bathroom. During interviews, one caregiver hospitality aide reported performing incontinent care without a CNA or nurse at bedside and stated she had taken courses but had not taken the certification test. Another caregiver hospitality aide stated he performed sit-to-stand transfers with residents and, when the only CNA on night shift was busy, he would obtain help from another hospitality aide to perform incontinent care and transfers; he reported having been shown how to do these tasks at another facility but confirmed he was not certified. The DON stated that hospitality aides did not have competency check-off lists, were not supposed to perform peri-care or transfers, and were not to do anything involving touching residents because they were not certified. The DON and the administrator both acknowledged there were no competency check-off lists for caregiver hospitality aides, that uncertified staff were not supposed to provide direct care unless paired with a nurse or CNA, and that staff performing direct care should have certification within four months of hire, identifying this as a system failure between nurses and staff with potential for residents to receive improper care from uncertified aides.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A nurse aide was employed beyond the allowed 4-month period without completing a State-approved CNA training and competency evaluation program. The aide had been hired but had not yet started CNA classes, and the HR Director stated the course should have been completed within 120 days of hire.
A staff member worked as an uncertified NA beyond the allowed 4-month period and performed direct resident care tasks while her CNA certification was not verified. She was assigned residents for many shifts and, according to interviews, helped with diaper changes, feeding, Hoyer lift transfers, and charting alongside a CNA. The ADSD and DON stated uncertified NAs were limited to supportive duties and should not provide direct care.
A nurse aide in training worked past the allowed 120-day period without completing a state-approved competency evaluation. The DON said the aide did not pass the test and did not report it, while the HR Director said monthly registry checks were missed because she was covering two roles. A labor report showed the aide worked 418 hours beyond the point when the competency evaluation should have been completed.
A nurse aide trainee failed to obtain CNA certification within the required 4-month period and continued working as a Nursing Assistant after the 120-day limit had expired. The DON confirmed the trainee remained on the unit past the allowed timeframe.
A facility failed to ensure a NA completed or enrolled in a state-approved training and competency evaluation program within four months of hire. Record review showed the NA had not obtained CNA certification or enrolled in a CNA program, and the HR Manager confirmed the NA had not completed the required training and should not have been working after the allowed timeframe.
A full-time nurse aide was allowed to continue working after failing to obtain CNA certification within the required timeframe. Records showed the aide completed facility training and skills check-off, but staffing schedules placed him as the only aide on multiple halls with one RN while interviews confirmed he had not passed the clinical exam and was still providing resident care. The ADON said he was kept on to help him get certified, while the DON and interim ADMN acknowledged he should not have remained in the aide role after the certification deadline.
Nurse Aide Training and Competency Requirements Not Met
Penalty
Summary
The facility failed to ensure that a full-time employee working as a nurse aide completed a State-approved training and competency evaluation program within 4 months of hire. The facility’s Nurse Aide and Certified Nurse Aide Hiring Policy stated that an individual may not be employed as a nurse aide for more than four months unless the applicable federal and state requirements for nurse aide employment have been met. Review of the personnel file for Nurse Aide #1 showed the aide was hired on 10/1/25 but had not started a CNA course as of the survey review. The HR Director stated on 8/5/26 that Nurse Aide #1 was scheduled to begin classes on 8/17/26 and acknowledged the course should have been completed within 120 days of hire.
Uncertified NA Worked Beyond Allowed Period and Performed CNA Duties
Penalty
Summary
The facility failed to ensure that one staff member who worked as an uncertified nursing assistant (NA) did not exceed the allowed 4-month period of NA employment and did not perform duties reserved for certified staff. The staff member was initially hired to the housekeeping department, later moved to the nursing department, and then worked as both a certified nursing assistant (CNA) and an uncertified NA from 5/1/2023 through 7/31/2024. The facility’s staffing assignment document showed the staff member had resident work assignments for 130 shifts during that period, but the employee file did not show a Nurse Assistant Certification. During interview, the staff member stated she completed a CNA program and began working as an NA shortly afterward while waiting for her certification card to arrive, but the certification never appeared. She stated that while waiting, she worked with another CNA and performed resident care tasks together, including changing residents’ diapers and clothing, passing meal trays, assisting with feeding, assisting with Hoyer lift transfers, and documenting in residents’ charts. The Assistant Director of Staff Development stated the staff member’s certification was not properly processed and that uncertified NAs should only perform limited tasks such as answering call lights and relaying information to certified staff. The ADSD and DON both stated NAs were allowed to work only for a four-month period while their certification was processed and verified, and that uncertified NAs should not perform direct resident care tasks after that period. The ADSD stated uncertified NAs could not assist with feeding, transfers, or charting, and the DON stated that having an NA perform CNA tasks placed residents at risk for quality of care and safety issues. The facility’s job descriptions also showed NAs were limited to supportive duties, meal tray distribution to residents who could feed themselves, housekeeping support, and transporting residents only after certified staff had safely transferred them to a wheelchair.
Nurse Aide Worked Beyond Allowed Training Period Without Competency Evaluation
Penalty
Summary
The facility failed to ensure that a nurse aide who had worked more than 4 months on a full-time basis completed a state-approved competency evaluation program. Review of Employee 1’s Nurse Aide Training Competency and Evaluation Program Certificate showed a course completion date of October 21, 2025, and the employee was allowed until February 21, 2026, to work independently and pass the exam to become a nurse aide. However, the employee remained working beyond that period without completing the required competency evaluation. During interviews, the DON stated that a nurse aide in training had worked past the 120-day limit because she did not pass the test and did not tell anyone. The HR Director stated she was working two roles at the time and was not checking the nurse aide registry monthly as usual; when she later reviewed the registry in June 2026, she could not find Employee 1’s name and contacted her, but received no response. The employee was terminated on June 15, 2026. The labor report showed Employee 1 worked 418 hours after the point when the competency evaluation should have been completed.
Nurse Aide Trainee Worked Beyond 120-Day Limit Without Certification
Penalty
Summary
The facility failed to ensure that a nurse aide trainee who did not become certified within four months was not working in the facility. Review of facility documentation dated September 30, 2025, showed that Employee E5 failed to obtain CNA certification within 120 days of working in a nurse aide training and testing program. The documentation further showed that E5’s 120 days ended on September 18, 2025, yet E5 continued working as a Nursing Assistant on the assigned unit from September 18, 2026, through September 30, 2026. During an interview on July 8, 2026, at 11:00 a.m., the DON confirmed that Employee E5 failed to become certified within four months and worked past the 120-day limit.
Nursing Assistant Training and Competency Deficiency
Penalty
Summary
The facility failed to ensure that nursing assistants had completed or were enrolled in a state-approved training and competency evaluation program within four months of hire. Record review showed that NA #1 was hired on 12/15/26 and had not obtained CNA certification and had not enrolled in a CNA program within four months of hire. During interview on 6/26/26 at 12:16 PM, the HR Manager confirmed that NA #1 had not completed the state-approved training and competency evaluation program and stated that NA #1 last worked on 4/30/26, confirming that NA #1 should not have been working after 4/15/26.
Nurse aide worked beyond certification timeframe
Penalty
Summary
The facility failed to ensure that a full-time nurse aide was certified within four months of hire. Record review showed the nurse aide was hired on 12/03/2025 as a nurse aide in training and had applied for a CNA position on 11/19/2025. The employee file included a pre-employment checklist indicating CNA certification verification was marked yes, but the checklist was not signed or dated by a staff member approving the aide to start employment. Training records showed the nurse aide completed a skills check-off on 12/22/2025 and received a NATCEP certificate dated 12/22/2025 for completing the nurse aide training program at the facility. However, staffing schedules showed the aide continued to work as the only nurse aide on halls with one nurse on multiple shifts from 04/23/2026 through 06/23/2026, including assignments on Hall C, Hall B, Hall A, and Hall D. The census report dated 06/23/2026 showed 24 residents on Hall B and 20 residents on Hall C. During interviews, the nurse aide stated he passed the written exam but did not pass the clinical exam on the first attempt and did not pass a later clinical attempt in April 2026. He stated the facility told him he should have been let go in April 2026 when he did not get certification, but that it was overlooked because of a change in ownership. The CNA stated he normally worked the 2 p.m. to 10 p.m. shift and was allowed to provide resident care with other staff present. The ADON stated the aide was allowed to continue working after failing the clinical test because the facility was trying to help him get certified, and the DON stated she expected nurse aides who could not obtain certification by 120 days after hire to be demoted to hospitality aides. The interim ADMN stated the aide should have been termed if unable to get certified within 4 months and stated the aide was termed on 06/24/2026 when the issue was discovered.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.