Uncertified Staff Member Performed Resident Care Duties
Summary
A deficiency was identified when a staff member assigned as a "Monitor" was found performing resident care activities, specifically Activities of Daily Living (ADLs), for a resident. The staff member, referred to as Monitor #1, did not possess a Certified Nurse Aide (CNA) license, as confirmed by a review of her personnel file and her own admission during an interview. Monitor #1 stated that she had attended CNA school and had taken the certification test but failed. Despite this, she reported performing tasks such as changing and caring for residents, which are duties reserved for certified and competent nurse aides. Further investigation revealed that facility leadership, including the Director of Nursing and other administrative staff, were not aware that Monitor #1 was providing direct resident care. The facility's job description for the "Monitor" position did not include providing resident care, but rather focused on supervision, assistance with transportation, and support during mealtimes and leisure activities. The facility was unable to provide an assignment sheet for the relevant date, and interviews confirmed that the Monitor was not authorized to perform CNA responsibilities. The resident involved had a history of cognitive impairment and required significant assistance with daily activities.
Plan Of Correction
F728 Hiring/Use of Nurse Aides 1. Corrective Action - On 4/10/25, monitor #1 received an education and disciplinary action for failure to adhere to their job description. - On [R], monitor #1 was terminated and is no longer employed at the facility. - On 4/10/25, HR Director audited all nursing assistant files to assure they are within their 120 days based on regulatory requirement. All nursing assistants (total of 11) met regulatory criteria for employment as nursing assistants. - On 4/10/25, HR Director audited all nursing assistants to ensure compliance with job description and scope of practice. - On 4/10/25, HR Director educated all monitors (9) on their job description. - On 4/10/25, HR Director audited all monitors' employee files for signed job description and not providing direct care to residents. 2. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measures Put Into Place: - HR Director and/or designee will audit monthly X6 months all nursing assistants to ensure that they do not work more than 120 days. - Director of Nursing/designee will audit the monitors' performance to assure it is compliant with their job description weekly X4 weeks and then monthly X6 months. 4. How Will These Actions Be Measured: - The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. - Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. - The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
The facility failed to ensure nurse aides were fully trained and competent or appropriately enrolled and supervised before working independently, as CNA students were scheduled and counted as regular CNAs with their own hall assignments. Staff interviews indicated that students who had not completed CNA classes or state testing were routinely used to fill CNA positions, contributing to perceived short staffing and workload issues. A CNA student reported being in an in-house CNA course for 1–2 months, completing online coursework and limited clinical days, yet being independently assigned to a hall and additional rooms on other days that were treated the same as clinical hours. The ADON and DON stated that once classroom work and skills sign-offs were done, they considered students able to work their own assignments and counted them as CNA staff on the schedule, affecting all residents in the building.
A nurse aide was hired and continued working without completing the required training and competency evaluation program within 4 months of hire. HR stated the aide was told how to obtain certification and that certification was required within 4 months, but no verification of completion was in the file, and the DON acknowledged the aide had worked longer than 4 months without certification.
The facility did not obtain direct verification from the Pennsylvania Nurse Aide Registry before allowing an agency nurse aide to work, despite a policy requiring verification of active licenses and certifications. Instead, the facility relied on a staffing agency that accepted an uploaded, falsified nurse aide license without independently verifying it. This led to an unlicensed nurse aide working multiple shifts in the facility before the issue was identified by the state Attorney General's Office and the aide was removed from the schedule.
The facility failed to ensure 2 nurse aides were certified within the required timeframe. Record review showed one aide had worked full time since hire without CNA certification, and another had worked full time with no evidence of certification. The DON and ADON stated they knew both aides had not been tested; one aide had taken the CNA class twice without passing and needed special testing accommodation, while the other had completed NA training and was waiting for a test date.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
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.
Use of CNA Students as Independent Staff Without Completed Training and Competency Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides had completed a training and competency evaluation program or were appropriately enrolled and supervised prior to working independently. Surveyors reviewed the resident roster showing 58 residents in the building and examined nursing and CNA schedules for the prior two weeks, which showed CNA students assigned their own halls on multiple dates. Staff interviews revealed that CNA students were being scheduled and counted as regular CNAs, assigned full hall responsibilities, and included in staffing numbers once they were “signed off” on certain skills, despite not having completed CNA certification or state testing. The facility’s DON acknowledged counting CNA students as independent staff members on the schedule once their skills were signed off and avoiding scheduling them in memory care only because there was a single CNA there. CNA staff reported that students were frequently working as part of the regular staffing pattern, being given their own assignments without being paired with a CNA for training. One CNA stated that there were supposed to be four CNAs on the south end but that they were short staffed and that students who had not finished class or testing were being given hall assignments. Another CNA reported struggling to complete showers and answer call lights while working with students who were treated as fully capable staff. A CNA student confirmed being in the facility’s CNA course for 1–2 months, taking online classes with clinical hours twice weekly, but also picking up additional days that were no different from clinical days, and being independently assigned to a hall and additional rooms. The ADON and DON both indicated their understanding that once classroom work and skills sign-offs were completed, students could work their own assignments prior to certification, which conflicted with the requirement that nurse aides be trained and competent or appropriately enrolled and supervised within the first four months of employment.
Nurse Aide Worked Beyond Required Training Period Without Certification
Penalty
Summary
The facility did not ensure that a nurse aide who had worked more than 4 months had completed a training and competency evaluation program within the required timeframe. Record review showed that Nurse Aide 1 was hired on 5/19/25 and, as of the personnel file review on 4/13/26, there was no verification on file of a completed nurse aide competency and certification course. During interview, Human Resources stated that the nurse aide was given information on how to obtain certification and how to be reimbursed by the facility, and that the nurse aide had been working without certification since being hired in May 2025. Human Resources also stated that the nurse aide signed a form acknowledging the education and the requirement to obtain certification within 4 months of hire, but that form was not provided to the State Survey Agency. The Director of Nursing stated he was aware that the nurse aide had been working longer than 4 months without obtaining certification.
Failure to Verify Nurse Aide Certification Prior to Allowing Work
Penalty
Summary
The facility failed to ensure that a Pennsylvania Nurse Aide Registry check was obtained prior to allowing an agency nurse aide to work in the building. Facility policy, last revised July 7, 2023, required that all offers of employment be contingent upon a thorough criminal background check and verification that any required license or certification was active and in good standing. Despite this policy, one agency nurse aide (Employee E3) worked multiple shifts at the facility without the facility obtaining direct verification of her nurse aide certification status from the Pennsylvania Nurse Aide Registry. The deficiency was identified after the Pennsylvania Attorney General's Office notified the facility that the agency nurse aide did not possess a valid nurse aide certification during the time she provided services. The facility had relied on the staffing agency to obtain and verify the nurse aide’s credentials. The facility’s investigation file included an email from the staffing agency stating that the nurse aide had submitted a falsified license document that appeared legitimate, and that the agency’s onboarding team had been accepting uploaded licenses from clinicians rather than independently running verification checks. As a result, the unlicensed agency nurse aide worked several dates at the facility before being removed from the schedule.
Uncertified nurse aides worked beyond required timeframe
Penalty
Summary
The facility failed to ensure that nurse aides were certified within the required time frame for 2 of 5 nurse aides reviewed, NA C and NA D. Record review showed NA C had a hire date of 4/08/2024, worked full time, and had no evidence of nurse aide certification. NA D had a hire date of 03/21/2025, worked full time, and also had no evidence of nurse aide certification. The report states that both aides had worked in the facility longer than four months without being enrolled in or having completed an approved training course. During interview, the DON and ADON stated the expectation was for the facility to have certified nurse assistants. The ADON stated that both she and the DON were aware that NA C and NA D had not been tested. She stated there had been no certified applicants and the facility had only been able to hire NAs. She also stated that NA C had previously been terminated for not having CNA certification, had taken the CNA class twice without passing the test, and required special accommodation for testing. NA D had completed NA training on 06/25/2025 and was waiting on a test date. The facility policy titled The Role of the Hospitality Aide described duties for hospitality aides, including non-nursing, non-direct care duties under supervision of licensed nursing personnel.
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