February 1, 2026
Uncertified but Responsible: CNA Orientation Gaps Put Residents at Risk
By Carol Lindsay, MSN, RN
A Story that Stopped Me Cold
While teaching a CNA class on death and dying, I asked my students how they explained a resident’s passing to others.
One young nursing assistant raised her hand: “We are told to say the resident has gone to Montana.” I assumed she was joking, but before I could question her further, another student from the same facility nodded. She admitted she had once told a resident her roommate wasn’t dead, just “in Montana.” The resident looked at her and said, “She’s not in Montana. She’s dead.”
“It just seemed wrong to say that, but it’s the policy,” she said.
I phoned the nursing director from the facility and asked if she was aware that the nursing assistants were telling residents that those who died were in Montana. She laughed. “I’m serious,” I said. The laughter stopped. After a pause, she admitted, “Oh dear, in the report when a resident has died, the nurses sometimes say they went to Montana.”
With a few careless words, the “Montana” euphemism for death morphed into a facility-wide “protocol.” Uncertified assistants were orienting one another, and misinformation was spreading unchecked and unquestioned by assistants who felt uncomfortable with the “policy” but did not know who to ask.
Where the Gap Begins
The story highlights a fundamental problem inherent in federal regulation. Under the Omnibus Budget Reconciliation Act of 1987 (OBRA), new nursing assistants can work for up to 120 days before completing certification.¹
The intent was practical: help facilities cope with staffing shortages. But in reality, it has created risky conditions:
- Untrained staff at the bedside: New hires often start care duties before learning infection control, communication, or safety basics.
- Peer-to-peer “training”: Instead of learning from licensed nurses, uncertified assistants absorb habits, both good and bad, from other certified or uncertified assistants.
- Little oversight: Federal and state surveyors rarely review how uncertified assistants are used during that 120-day window.
A 2023 national survey found wide variation in CNA requirements across states, from 75 training hours at the bare federal minimum to more than 100 hours in others, with inconsistent support for dementia and ESL.² That inconsistency creates confusion and inequity.
Why It Matters
This isn’t just a paperwork issue. Research shows:
- Turnover risk: CNAs without structured orientation are more likely to leave within months.
- Resident safety: Nursing assistants may not know core skills like safe transfers, infection prevention, or how to communicate about end-of-life care.
- Equity: CNAs are disproportionately women, immigrants, and English as a Second Language (ESL) learners. Starting them off with guesswork instead of real training sets them up to fail.
The Centers for Medicare & Medicaid Services’ 2023 Nursing Home Staffing Study emphasized that raising staffing numbers alone won’t improve care; training and retention must go hand in hand.³
What Facilities Can Do Now
Regulatory reform is overdue, but waiting for Congress or CMS isn’t enough. Facilities can take practical steps today:
- Front-load basics: Require new assistants to complete a short preservice module (infection control, resident rights, communication) before resident contact.
- Assign mentors: Pair each new assistant with a certified, experienced CNA, not another new hire.
Document enrollment: Ensure every NA is officially enrolled in a training program within weeks of hire. - Make orientation consistent: Provide checklists and structured shadowing instead of “learn as you go.”
A Call to Action
The “Montana” story might make us smile, but it highlights a serious issue. When orientation is left to rumor and survival training, residents suffer, and unsupported new CNAs burn out.
The 120-day allowance was designed to help facilities weather shortages. But without structured onboarding, it ends up doing the opposite: weakening both safety and retention.
Residents deserve competent caregivers from day one. And CNAs deserve the respect of being prepared for the work they are asked to do.
Takeaways for Facilities
- Don’t let the 120-day window become a loophole.
- Provide a preservice “safety and rights” module before floor work.
- Pair new assistants with trained mentors, not other novices.
- Track and document CNA training enrollment from day one.
References
- Omnibus Budget Reconciliation Act of 1987, Pub L No. 100-203, 101 Stat 1330 (1987).
- Harris-Kojetin L, Sengupta M, Lendon JP, Rome V, Valverde R, Caffrey C. Long-Term Care Providers and Services Users in the United States, 2017–2018: National Study Findings. National Center for Health Statistics; 2023. Accessed October 2, 2025. https://www.cdc.gov/nchs/data/series/sr_03/sr03-046-508.pdf
- Centers for Medicare & Medicaid Services. Nursing Home Staffing Study: Final Report. CMS; 2023. Accessed October 2, 2025. https://www.cms.gov/files/document/nursing-home-staffing-study-final-report-appendix-june-2023.pdf
Carol Lindsay is a long-term care ombudsman.