Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A nursing assistant who had completed CNA coursework but had not passed the state certification test was allowed to work as a CNA for longer than the four months permitted for uncertified aides. Human Resources confirmed the staff member continued working past the allowed period, resulting in non-compliance with staff qualification requirements and potentially affecting all residents.
The facility failed to ensure nursing assistants received required training before providing direct care, affecting all 46 residents. A nurse aide in training performed duties without formal training, and several nursing assistants were hired without being on the nurse aide registry or enrolled in training programs. The facility believed they had four months to enroll aides in classes, but some worked longer without enrollment.
Unqualified Nursing Assistant Worked Beyond Permitted Timeframe
Penalty
Summary
The facility failed to ensure that a nursing assistant was properly qualified to provide resident care, as required by regulations. Record review showed that a nursing assistant was hired after completing a CNA course but had not passed the state certification test. Despite this, the staff member worked as a CNA for a period exceeding the four months allowed for individuals who have not yet obtained certification. Human Resources confirmed that the nursing assistant continued to work past the permitted timeframe without having passed the state test, resulting in non-compliance with staffing qualification requirements. This issue had the potential to affect all 142 residents in the facility, as the staff member was involved in direct resident care.
Failure to Ensure Proper Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that nursing assistants received the required training before providing direct care to residents, potentially affecting all 46 residents. Employee #145, a nurse aide in training, had not started formal training classes but was performing duties equivalent to a state-tested nursing assistant, including helping with meals, providing showers, and incontinence care. Despite having previous experience in a group home, Employee #145 had not received dementia training or training on handling aggressive behaviors. The Human Resource employee confirmed that Employee #145 was not enrolled in classes and was functioning as a state-tested nursing assistant based on the Administrator's instructions. Additionally, the facility hired several nursing assistants who were not on the nurse aide registry at the time of hire and were not enrolled in nurse aide registry classes or nursing school. These employees, including STNA #155, STNA #120, and STNA #110, had their skills checked off on orientation checklists despite not being registered or enrolled in training programs. The Human Resource employee verified that the facility believed they had four months to enroll aides in classes, and some employees had worked longer than four months without being enrolled in the NATCEP program, as the Administrator decided the timing of enrollment.
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