Basic Nursing Skills
The 22 CNA skills tested on the California Manual Skills Exam — vital signs, bedmaking, perineal care, transfers, feeding, ROM — are the daily work and the largest weighted topic on the written exam. They are governed by 42 CFR §483.25 (Quality of Care), Title 22 CCR §72311, and the scope-of-practice rules CDPH maintains for Certified Nurse Assistants under HSC §1337.
Vital signs: the numbers that protect the resident
Temperature, pulse, respirations, blood pressure, and oxygen saturation are the basic vitals a CNA collects and reports. Normal adult ranges to know: oral temperature 97.6 to 99.6 °F (axillary runs about a degree lower, rectal a degree higher); pulse 60 to 100 beats per minute, regular; respirations 12 to 20 per minute; blood pressure systolic under 130, diastolic under 80 in current guidelines; SpO2 95% or higher on room air. Count respirations without telling the resident — people change their breathing when they know they are being watched. Count for a full minute when the pulse is irregular. Use the correct cuff size: a cuff too small reads falsely high, a cuff too large reads falsely low. Report immediately any temperature over 100.4 °F, pulse under 60 or over 100, respirations under 12 or over 20, systolic over 180 or under 90, or SpO2 under 90% — those are the thresholds where a CNA must notify the licensed nurse without finishing the round first. Title 22 CCR §72311(a)(1) makes nursing assessment the licensed nurse's job; you collect data, the nurse interprets and orders intervention. Charting on rounded numbers ('about 80') is unacceptable — write the exact reading.
Activities of Daily Living: bathing, dressing, grooming, toileting
ADL care is the heart of CNA work, governed by 42 CFR §483.24, which requires that a resident's abilities in activities of daily living not diminish unless circumstances of the resident's clinical condition demonstrate that decline was unavoidable. Translation: if your resident loses the ability to feed themselves on your watch and there is no medical reason, the facility owes the surveyors an explanation. Practical principles: provide privacy with curtain and door, gather supplies before you start so you never leave the resident exposed, work from clean to dirty in perineal care (front to back for females, around the meatus first for males), check water temperature at 105 °F maximum to prevent burns, encourage the resident to do what they can themselves to preserve function, and inspect the skin during every bath — pressure areas, reddened heels, perineal breakdown. Report any skin change. Oral care is required at least twice a day, including for residents who are NPO (nothing by mouth) and residents with dentures — dry mouth and aspiration of mouth bacteria are leading causes of nursing-home pneumonia. Hair, nails, and shaving are dignity items, not optional.
Transfers, ambulation, and range of motion
Transfers are the most common moment of injury for both resident and CNA. Follow the care-plan transfer level exactly: independent, supervision, one-person assist with gait belt, two-person assist, mechanical lift (sit-to-stand or full Hoyer-style sling lift). Before any transfer, lock the bed brakes and the wheelchair brakes, position the chair on the resident's strong side, use a gait belt around the waist (not over a colostomy or recent surgical site), and count out loud so the resident moves with you. For ambulation, walk slightly behind and to the weak side, holding the gait belt — never grab the resident's arm, which can cause skin tears in fragile elderly skin and gives you no control if the resident starts to fall. If a resident begins to fall during ambulation, ease them down along your leg to the floor, protecting their head — never try to catch a full adult weight, because that is how you blow out your back and they break a hip on the way down. Range-of-motion exercises (active when the resident moves, active-assisted when you help, passive when you move the joint for them) preserve joint function; perform gently, never past the point of pain or resistance, supporting above and below the joint. These tasks fall within CNA scope under HSC §1337 and the CDPH Approved Training Curriculum.
Nutrition, hydration, and feeding assistance
Unintended weight loss and dehydration are sentinel events in nursing homes — 42 CFR §483.25(g) requires the facility to maintain acceptable parameters of nutritional status and offer sufficient fluids. The CNA observes intake and output and reports problems. Position the resident upright at 90 degrees for meals, never feeding in a flat or reclined position. Allow time — rushing is the leading cause of aspiration. Offer small bites, alternate solids and liquids, watch for pocketing of food in the cheek, and stop and call the nurse at any sign of choking, coughing, or wet gurgly voice. Residents on thickened liquids, pureed diets, or with NPO orders are on those orders for a clinical reason; never freelance the diet because the resident asked nicely. Many California SNF residents come from food traditions — Filipino, Vietnamese, Mexican, Chinese — that the facility menu does not match well, and that mismatch can cause refusal and weight loss. Document refusals, report patterns to the nurse, and advocate for cultural-food substitutions through the care-plan meeting. Hydration: offer fluids every contact, watch for dark urine and dry mucous membranes, and remember that residents with dementia often forget to ask.
Skin integrity and pressure injury prevention
Pressure injuries (formerly 'pressure ulcers' or 'bedsores') are largely preventable, and 42 CFR §483.25(b) holds the facility responsible: a resident who enters without a pressure injury should not develop one unless clinically unavoidable, and existing injuries must receive treatment and care to promote healing. The CNA prevents pressure injuries by turning and repositioning at least every two hours for bedbound residents (use a turning schedule and document it), shifting weight every 15 minutes for chair-bound residents, keeping skin clean and dry (incontinence is a major driver), using pillows and wedges to off-load bony prominences (sacrum, heels, elbows, ears), and reporting any new red area that does not blanch under pressure. Heels are the highest-risk site and the most often missed — float them off the bed with a pillow under the calves. Never massage a reddened area; massage shears already-compromised tissue. Stage 1 (non-blanching redness) is reportable immediately; by Stage 2 (open blister or shallow ulcer) the resident has skin loss that may take months to close. Diabetic residents, residents on steroids, and residents with poor nutrition are highest risk.
Last updated: May 2026