Facility Lacks Qualified MDS Coordinator
Summary
The facility failed to ensure that qualified staff were employed to accurately encode, transmit, and implement assessments and care plans. The Minimum Data Set (MDS) Coordinator position, responsible for completing all MDS and Care Area Assessments (CAAs), scheduling and leading Care Plan Conferences, and transmitting completed MDS assessments to the state, was vacant after the previous coordinator left on 08/14/2024. The Director of Nursing (DON), who lacked training in MDS, was temporarily assigned these duties with assistance from an MDS Consultant. However, the consultant was not available for interviews, and the DON admitted to not being familiar with the MDS process. The Administrator acknowledged that the workload assigned to the Assistant Director of Nursing (ADON), who was also handling admissions, infection prevention, assessments, and other duties, was unrealistic for long-term success. The facility was in the process of hiring new staff to fill the DON and MDS positions, but at the time of the survey, the ADON was overwhelmed with responsibilities, and the facility was not in compliance with state regulations requiring qualified staff for MDS tasks.
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.
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.
The facility failed to ensure that an LN maintained a valid, active nursing license while providing care. One LN’s license had lapsed, as confirmed through Nursys and the state board verification system, yet the LN continued working for an extended period. Interviews with administrative and nursing leadership revealed that HR was responsible for license verification and tracking expirations, but due to multiple HR staff turnovers, required checks of nursing licenses and the nurse aide registry had not been kept current, contrary to the facility’s own background screening policy.
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.
A facility allowed an LVN to work 14 shifts with an expired nursing license, contrary to its own job description requiring a current, active license. The LVN reported believing the license was still active and was unaware it had expired until it was renewed 22 days after the expiration. A review of state licensing records confirmed the license had gone delinquent and inactive due to failure to renew, and the DON acknowledged that the facility’s requirement for an active license was not followed, potentially affecting 59 highly vulnerable residents.
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.
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.
Failure to Ensure Licensed Nurse Maintained Active Nursing License
Penalty
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.
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.
Unlicensed LVN Worked Multiple Shifts with Expired License
Penalty
Summary
The facility failed to ensure that a licensed vocational nurse (LVN) held a valid and current license while working, resulting in one LVN working with an expired license for multiple shifts. A letter from the Board of Vocational Nursing and Psychiatric Technicians showed that the LVN’s license became delinquent and inactive after it was not renewed, and it was not renewed again until 22 days after its expiration. Review of the facility’s Nursing Staff Assignment and Sign-in Sheets showed that this LVN worked 14 shifts during the period when the license was expired. In a telephone interview, the LVN stated she believed she was working with an active license and was unaware it had expired. During a concurrent interview and record review, the DON confirmed that the facility’s job description for LPN/LVN required a current, unencumbered, active license to practice in the state and acknowledged that this requirement was not followed. This failure had the potential to place 59 highly vulnerable residents at risk due to the LVN’s non-compliance with the legal requirement to practice nursing.
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