Health inspection·February 19, 2025

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure professional staff were licensed, certified or registered in accordance with applicable state laws for one (ADON) of four licensed nursing staff reviewed for staff qualifications. Residents Affected - Some The facility failed to ensure the ADON's Nursing license was not expired. The past noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for receiving nursing services by an unlicensed nurse. Findings included: During an interview, on [DATE] at 2:30 pm, the HR Manager stated the staff licenses were checked upon hire. She stated when staff came in for background checks, all the other checks were completed. She stated the facility noted the expiration date of the license or certification and let the staff know when the license would expire, and at that point it was the employees' responsibility. She stated effective [DATE] the responsibility was given to the HR Manager, to maintain verifivcation of the licenses and certifications. She stated that prior to the assignment being the responsibility of the HR Manager, there were 2 other staff that had that responsibility. She stated that she assumed that other staff were not doing their job and missed the expiration of the license. She stated that she started early, on [DATE], and checked the registry and found the ADON's license was expired effective [DATE]. She stated that she informed the Administrator and DON, she stated that at that time she let both of them know to take her off the floor. She stated the ADON was removed from the floor and fired [DATE]. During an interview on [DATE] at 2:55 pm. The Administrator stated the ADON submitted her resignation after a personal issue with the facility on [DATE]. She stated the HR Manager made her aware the ADON's nursing license expired effective [DATE] on [DATE]. She stated the ADON was fired at that time the HR Manager informed her of the license issue. She stated Human Resources and the individual staff were responsible for keeping up with the licenses and certifications. She stated after this incident the DON and HR Manager monitored the license and certifications for staff members. She stated they made a referral to the nursing board for the ADON not maintaining her license. She stated they created an Excel Spreadsheet with all of the licenses and training certifications for all CNA and Nursing staff. She stated the DON currently monitors the sheet and keeps her updated weekly on upcoming expirations. She stated the HR Manager also has a spreadsheet and monitors licenses and certification. She provided updates to the Administrator and DON when someone 's license was nearing Page 1 of 2 455617 455617 02/19/2025 Christian Care Communities and Services Mesquite 1000 Wiggins Pkwy Mesquite, TX 75150

F 0839 expiration. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 3:45 pm, the DON stated that each nurse was responsible for making sure the their own license was current. She confirmed the ADON worked at the facility fulltime and during the time the licensed was expired. She stated that prior to this incident HR and each staff member kept up with the license. She stated that it was the individual staff''s responsibility to keep up with their own license. She stated with the current process she maintained a spreadsheet with the expiration dates of trainings, certifications and licenses for both CNA and Nurses. She stated that she and the HR manager both monitor the spreadsheet. She stated that she checked the list almost daily and sent out reminders to the staff with upcoming certification and license expirations. The DON stated with some staff she would start months out sending out reminders. She stated the risk to residents was minimal as the nurse was licensed and had practiced for several years. She stated she understood that Nurses needed to be licensed to practice nursing. Residents Affected - Some Review of Facility Self Report dated [DATE] regarding the incident that occured on 12.30.24 revealed the following: The facility conducted an audit to ensure no other concerns regarding expired licenses. Results of the audits reflected no new findings or negative outcomes. No other nurse license was expired. In-services were completed by HR by Administrator on [DATE].HR Monthly Tracking. Results of audits will be tracked and presented to QAPI for review. Recommendations and follow-up based on outcomes will be determined and appropriate performance improvement will be developed Record review of a facility provided in-service dated [DATE] consisted the following staff: the DON, 2 Nursing managers, VP of Clinical Services, Medical Director, Administrator and another staff member. This in service listed all Nursing staff with licenses expiring in the calendar year 2025. During the in-service the Excel spreadsheet was created and all staff members licenses certifications and trainings were listed on the spreadsheet. Review of the undated tracking form/Excel spreadsheet with staff names/license and expiration date revealed all staff licenses were current. The tracking from had monthly check off dates for each month for the entire year. Record Review of the facility background check policy, with an effective date [DATE] page 15 states The Community also checks the CNA Registry, the Abuse/Misconduct Registry, the Department of Health and Human Services Office of Inspector General(OIG) List of Excluded Individuals/Entities, and any other federal and state registries per federal and state law, on all individuals who have been offered and accepted a position and regularly thereafter on all teammates. If an individual is listed on any registry for misconduct or on the OIG list, they may be subject to disciplinary action, up to and including termination. 455617 Page 2 of 2