Failure to Ensure Licensed Nurse Maintained Active Nursing License
Summary
The deficiency involves the facility’s failure to ensure that a licensed nurse maintained a valid, active nursing license while working. The facility had a census of 54 residents with a sample of 14 residents. Facility documentation dated 02/17/26 showed that an administrative staff member identified that one licensed nurse’s (LN H’s) nursing license had lapsed on 11/30/25. The facility verified the lapse through searches on the Nursys national nurse licensure database and the Kansas State Board of Nursing (KSBN) verification website. On 03/23/26, surveyors independently confirmed via Nursys and KSBN that LN H’s license had lapsed on 11/30/25, yet LN H continued to work at the facility with the lapsed license until 02/17/26. Administrative staff interviews revealed that human resources (HR) staff were responsible for verifying valid licenses and tracking expiration dates, but this process had not been maintained. An administrative nurse stated that recent turnover in HR staff contributed to nursing license and nurse aide registry checks not being kept up to date. Another administrative staff member reported that, after turnover of three different HR staff in the prior six months, she discovered that nursing license verifications had not been completed for some time. The facility’s Background Screening Investigations policy, dated November 2023, documented that for any licensed professional applying for a position involving direct resident contact, the respective licensing board is to be contacted to determine if any sanctions have been assessed against the applicant’s license.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LVN worked with an expired license after the facility failed to properly verify her credential status. The DON was unaware of the expired license, and the Administrator said the issue was found during an audit of licensed nurses. HR stated license checks were done on hire and annually, but the report used did not fully show the expiration date. The LVN said she did not know her license had expired.
Expired Nursing License: The facility failed to ensure an LVN maintained an active license while working as a nurse. Record review showed the LVN worked multiple shifts during the review period, and the BOM stated the LVN was later sent home after the facility found the license had expired. The BOM and ADM stated the BOM was responsible for checking nursing staff licenses, and the facility policy required current licensure verification and recertification before expiration.
A nurse was hired and worked as an RN for an extended period without a valid Arizona RN license after HR verified the wrong individual’s license based on a similar name and did not obtain a copy of the actual license. The nurse functioned as a floor RN, passing meds and assessing residents, while only holding an RN license from a non-compact state and awaiting Arizona endorsement. AZBN later informed HR that the nurse did not have an active Arizona license and should not be working as an RN, but the nurse continued to be scheduled for several days after this notification. The Administrator and DON initially believed or assumed the out-of-state license allowed practice, and only later confirmed that the other state was not part of the Nurse Licensure Compact, contrary to facility policy requiring verification and documentation of valid licensure before staff work in licensed roles.
Unlicensed RN Assigned to Direct Resident Care: A nurse was assigned as a floor nurse and medication cart nurse providing direct resident care even though the RN license had expired. The employee file lacked clear verification of an active license, the DON confirmed the nurse was doing direct care, and the Administrator said HR was responsible for checking licenses before hire but there was no indication this was done.
The facility failed to ensure that a nurse employed in a supervisory RN role held an active, recognized RN license consistent with state requirements. A nurse with a Virginia compact RN license, later suspended, was working while the Maryland Board of Nursing did not recognize the license due to graduation from a non-approved program. The nurse also held a Maryland LPN license and was reportedly changed from an RN to an LPN supervisor, but facility HR could not provide documentation of when this change occurred or when the RN license was forfeited. Review of the nurse’s education and licensure history showed the school attended was removed from the state’s approved list for LPN programs before the LPN license was issued.
Failure to verify an LPN license upon hire: An LPN was observed working on a unit even though the personnel file did not contain proof of a valid PA license at the time of hire. The DON stated the LPN had been sent home after HR found inadequate proof of licensure, and time punches showed the LPN worked multiple shifts before the license was issued. Facility policy required license verification prior to or upon employment before direct resident care could be provided.
Expired LVN License Not Identified
Penalty
Summary
The facility failed to ensure that one of six licensed staff reviewed, LVN B, maintained an active nurse license in accordance with state law. Record review showed LVN B was hired at the facility and that a Texas Board of Nursing verification checked by the facility showed her license had expired. A daily staffing assignment/sign-in log also showed LVN B worked on a day after the license expiration was identified in the record review. During interviews, the DON said she was not aware LVN B had an expired nurse license. The Administrator said she learned of the expired license during an audit of licensed nurses and stated LVN B was immediately removed from the schedule. HR said license checks were done on hire and annually, but the last check of licensed staff was completed in [DATE] and LVN B's expiration was missed because the report was not fully reviewed to see the expiration date. LVN B said she did not know her license had expired and stated she had last renewed it in [DATE]. The facility policy on credentialing nursing service personnel required staff who provide resident care or treatment within the scope of their license or certification to present verification of such license.
Expired Nursing License
Penalty
Summary
The facility failed to maintain sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 5 nursing staff reviewed, LVN C. Record review showed LVN C had an LVN/LPN license with an expiration date listed in the employee record, and the facility's punch-detail report showed LVN C worked multiple shifts over the reviewed period, including 11.1 hours, 11.08 hours, 11.93 hours, 11.17 hours, 12.07 hours, 9.07 hours, 5.0 hours, 10.92 hours, 3.03 hours, and 12.82 hours. During interview, the BOM stated she had checked LVN C's license and the expiration date was correct, but also stated LVN C was sent home the day before the interview when the facility checked her license and found it was expired. The BOM stated it was her responsibility to check nursing staff licenses and certificates, that she checked licenses upon hire, and that she had been trained to do so. The ADM stated the BOM was responsible for checking nursing staff licenses/certificates and expected all licensed individuals to be up to date when required. The facility policy required employees who need a license, certification, or registration to present verification prior to or upon employment and to provide recertification before expiration.
Unlicensed RN Allowed to Work Due to Faulty License Verification
Penalty
Summary
The facility failed to ensure that a licensed nursing staff member possessed a valid Arizona RN license during the entire period of her employment as an RN. The staff member applied for employment in March 2025 and indicated on her application that she held a valid RN license, with a handwritten note that she was to be endorsed upon arrival. A license verification report dated March 31, 2025, in her personnel file showed an active, unencumbered RN license for a different individual with the same first and last name but a different middle initial. There was no evidence in the personnel file of a valid Arizona RN license or any other state license verification belonging to this staff member, despite her being hired and classified as an RN. Staffing and payroll records showed that the staff member worked as a floor RN from mid-April 2025 until mid-February 2026, passing medications and assessing and caring for residents. A CNA reported that this RN functioned as a floor nurse, and that floor nurses are responsible for assessing residents when notified of changes in condition. The Arizona State Board of Nursing (AZBN) confirmed that the staff member had only been an RN license applicant by endorsement in Arizona and that she was considered foreign-educated, requiring additional steps such as language proficiency testing and third-party education verification. The AZBN stated that the staff member never held an Arizona RN license until April 6, 2026, and that she had been working at the facility as an RN without Arizona licensure or endorsement. The AZBN notified the facility’s HR Director on February 4, 2026, that the staff member did not have an active Arizona RN license and should not be working as an RN. The HR Director acknowledged that she was responsible for obtaining onboarding documents and verifying licenses via an online portal, and that the process did not include requesting a copy of the nursing license. She recognized that the verification in the file belonged to a different person and described this as an oversight. Despite the AZBN notification, payroll records showed that the staff member continued to work until February 11, 2026. The Administrator and DON both stated that they believed the staff member had an active license from another state and, at least initially, believed or assumed that this allowed her to practice, though the other state was not part of the Nurse Licensure Compact. The DON later confirmed via the compact website that the other state was not a compact state and that endorsement through Arizona was required. The facility’s written policy required verification of current, valid licensure and placement of license verification documents in the applicant’s file, which was not done correctly for this staff member, resulting in her working as an RN without a valid Arizona license for an extended period. The staff member herself stated that she first applied for an Arizona RN license sometime in 2024, did not receive it, then obtained an RN license from another state in March 2025 and subsequently applied for Arizona licensure by endorsement. She reported ongoing difficulties completing Arizona’s requirements, including language proficiency testing and education verification, while she was working at the facility. She stated that she believed she could work under her other state license and assumed it would be acceptable. She also reported that the HR Director had asked her shortly before the AZBN’s February 2026 call whether her Arizona license had arrived, and she replied that she was still working on the requirements. The Administrator later acknowledged that the license verification in the file was for another person and that, per facility policy, the staff member had not been qualified to work as an RN during the time she was employed in that role.
Unlicensed RN Assigned to Direct Resident Care
Penalty
Summary
The facility failed to ensure professional staff were licensed in accordance with State law when it assigned a nurse to direct resident care without an active RN license. Review of the employee file for Nurse #5 showed the nurse was hired on [DATE], but the RN license had expired on [DATE]. The printed license verification did not include the date the information was obtained, and the job description required a current Massachusetts RN license for the position. During interviews, the Administrator stated Nurse #5 came forward during the survey week to report she did not have an active nursing license, and said Human Resources was responsible for checking licenses before hire. The Director of Nurses stated Nurse #5 was a floor nurse assigned to a medication cart and had been providing direct resident care. The employee time sheet showed Nurse #5 worked multiple shifts as a floor nurse doing direct resident care after the license had expired. A representative from the Massachusetts Bureau of Health Professions Licensure confirmed the RN license had expired and had been expired since that date. The Assistant Director of Nurses stated Nurse #5 completed her shift on the first day of survey, left the facility, and then notified the facility that she did not have an active license.
Failure to Verify and Maintain Appropriate Nursing Licensure for Supervisory Role
Penalty
Summary
The deficiency involves the facility’s failure to ensure that employed nursing staff held active professional licenses consistent with state law and their job descriptions. A complaint alleged that a registered nurse was employed as an RN supervisor without an active license over a defined period. Review of this staff member’s personnel file showed that the individual held an RN license issued in Virginia with compact designation, but that license was suspended several months after issuance. The personnel file also listed Maryland as the staff member’s primary address. The Maryland Board of Nursing did not recognize this nurse’s license because the nurse graduated from a program that was not approved by the Board. Further review and interviews revealed that the nurse had an active Maryland LPN license and that her role at the facility was changed from RN to LPN supervisor, but the human resources representative could not recall or provide documentation of when this role change occurred. The HR representative stated that all RNs licensed from Florida had to either sit for the Maryland Board of Nursing exam or forfeit their license, and that this nurse forfeited the RN license, but HR could not provide documentation of when this occurred. In an interview, the nurse reported graduating from VMT Education Center and later sitting for the Maryland LPN boards, stating that she delayed testing because the school would not release her transcript due to unpaid tuition. Review of the Maryland Board of Nursing and VMT Education Center information showed that VMT was not recognized by the Board and had been removed from the approved list because it did not meet LPN qualifications, and that the nurse’s LPN license was issued months after the school’s removal from the approved list.
Failure to Verify LPN License Upon Hire
Penalty
Summary
The facility failed to ensure that professional staff were licensed, certified, or registered in accordance with state law upon hire for one of five personnel files reviewed, Employee 2, an LPN. Facility policy required nursing service personnel who need a license or certification to present verification prior to or upon employment and prohibited them from performing direct resident care until licensing and background checks were completed. Pennsylvania law and the facility policy were reviewed during the survey, and observation on February 18, 2026, at 10:30 AM showed Employee 2 working on D Hall on Unit 2. Review of Employee 2’s personnel file showed she was hired as an LPN on January 28, 2026, had completed a Practical Nursing Program Diploma, and passed the Practical Nurses Exam, but there was no evidence of a Pennsylvania Practical Nurse license in the file at the time of hire. Time punches showed she worked multiple shifts between January 28, 2026, and February 17, 2026, before a license was issued on February 18, 2026. The DON stated Employee 2 had been sent home after HR found inadequate proof of a valid Pennsylvania LPN license, and the NHA confirmed HR did not complete license verification upon hire as required by facility policy.
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