Deficiency in Nurse Aide Performance Reviews and In-Service Training
Summary
The facility failed to ensure that each nurse aide received a performance review at least once every 12 months and regular in-service education based on the outcomes of these reviews. This deficiency was observed on the 5th Floor of the facility, where 6 out of 6 Certified Nursing Assistant (CNA) personnel files lacked evidence of performance evaluations and in-service training based on evaluation results. The facility's assessment documented that staff were expected to have competencies in various areas, including abuse, resident rights, and dementia care, but there was no documented evidence that these competencies were part of the orientation or annual in-service package. The facility's survey report indicated that each nurse aide was required to receive 6 hours of paid in-service training every 6 months, but the review of personnel records showed no evidence of the required 12-hour annual in-service training. Additionally, the facility did not include behavioral health care and management in the list of in-service topics provided to staff. The Human Resources Director acknowledged communication issues between Human Resources and the Nursing Department, which affected the handling of disciplinary actions and performance evaluations. The facility also lacked an Inservice Educator, as the position was absorbed into the Director of Nursing's responsibilities. Interviews with the Director of Nursing and the Assistant Director of Nursing revealed inconsistencies in conducting competency evaluations and in-service training for nursing staff. The Director of Nursing admitted that the system for ensuring competency evaluations was inadequate, and the Assistant Director of Nursing stated that they only conducted evaluations related to specific incidents or complaints. The Administrator was unsure if competencies and performance evaluations were being performed as required, indicating a lack of oversight and accountability in the facility's processes for maintaining staff competencies.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Complete Annual CNA Performance Evaluations: The facility did not complete annual performance evaluations for two CNAs. A file review showed no annual evals for CNA 3 and CNA 4 for the review period, and the DSD confirmed both were missing. The ADM stated annual evaluations are important for identifying staff issues and additional training needs, and the facility policy requires each employee to receive an annual performance evaluation review.
The facility failed to complete a required annual CNA performance review for one CNA, Employee #8, whose personnel record had no documented evaluation. The HR Director stated CNA evaluations were done each year on Oct. 1 to review the prior year and confirmed this CNA was not reviewed 12 months after starting at the facility. The Facility Assessment stated weaknesses identified in CNA performance reviews and annual competency assessments would be addressed through in-service training.
Missing CNA Annual Performance Evaluation: The facility failed to complete and maintain the annual performance evaluation for one CNA. The CNA's file had no current evaluation, and the DSD and DON stated the review should have been done annually, including when the CNA returned from leave and light duty. The employee handbook stated staff generally receive performance evaluations and that work during the year is evaluated by the supervisor.
Surveyors determined that the facility did not complete required annual performance evaluations or provide the mandated 12 hours of annual in‑service education for multiple nurse aides. During interviews, the HR Director acknowledged that annual performance reviews had not been done, and the Nursing Home Administrator confirmed that the affected nurse aides had not received the required in‑service hours within 12 months of their hire date anniversaries.
The facility failed to complete annual performance evaluations for three NA personnel records as required by policy. Review of the files for three NAs showed no evaluations completed at least every 12 months, and the NHA stated the issue was discovered after prior HR staff were not completing staff education correctly.
Failure to complete CNA annual performance reviews was cited for 3 of 5 sampled CNAs. One CNA had no annual review on file, and two CNAs had reviews completed months after their hire anniversaries. The DON stated the reviews were completed within the year, but the regulation is based on the hire date and anniversary date, not the calendar year.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed for two Certified Nursing Assistants, CNA 3 and CNA 4. During a review of five employee files, the annual evaluation audit did not show a completed 2025-2026 evaluation for CNA 3, whose date of hire was 6/29/2015, or for CNA 4, whose date of hire was 3/15/2023. In an interview, the Director of Staff Development stated both CNAs did not have annual evaluations completed for the year 2025-2026 and stated annual evaluations should have been completed to ensure staff were compliant with facility policies and expectations. The Administrator stated annual evaluations were important because they gave management the opportunity to address issues staff needed to improve on or issues requiring additional training. The facility policy titled Annual Performance Evaluation dated 7/2019 stated that annually, each employee will receive a performance evaluation review.
Missing Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure a nurse aide performance review was completed at least once every 12 months and that areas of weakness were identified and addressed for 1 of 2 sampled CNAs, Employee #8. Employee #8 was hired as a CNA on 10/21/2024, and the personnel record lacked documented evidence of a nurse aide performance evaluation. During interview on 04/22/2026, the HR Director stated CNA performance evaluations were completed every year on October 1st to review the prior year and explained that, because of the date of hire, Employee #8 was not reviewed for performance. The HR Director confirmed Employee #8's nurse aide performance review was not completed 12 months after starting at the facility. The Facility Assessment, updated 03/2026, documented that areas of weakness identified in nurse aide performance reviews and annual competency assessments would be addressed through in-service training.
Missing CNA Annual Performance Evaluation
Penalty
Summary
The facility failed to conduct the CNA annual performance evaluation for one of three sampled employees, CNA M. Review of the employee file showed CNA M was hired on 7/9/2013, but there was no current annual performance evaluation in the file. The report stated this evaluation was a formal, documented review of the employee's work over the past year, assessing performance against established goals and expectations. During interviews, the DSD stated the business office records showed CNA M's last annual performance evaluation was on 8/27/2023, but the hard copy could not be found and the date was known only because CNA M received a raise that day. The DON stated the evaluation should have been done annually and was not sure why it was missed. In a follow-up interview, the DSD stated CNA M went on leave in 6/2025 and returned on light duty on 1/18/2026, and confirmed the performance evaluation should have been completed when she came back to work. The employee handbook stated staff members generally receive a performance evaluation at the same time, generally in December, and that work during the year will be evaluated by the supervisor.
Failure to Complete Annual Nurse Aide Performance Reviews and In‑Service Education
Penalty
Summary
The facility failed to complete required annual performance reviews and provide mandated annual in‑service education for nurse aides. Surveyors reviewed facility documents and interviewed the Human Resources Director, who confirmed that annual performance evaluations had not been completed for five of five nurse aides (Employees E2, E3, E4, E5, and E6). In a separate interview, the Nursing Home Administrator confirmed that these same nurse aides had not received the required 12 hours of annual in‑service education within 12 months of their hire date anniversary, as required by federal and state regulations. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on the facility’s failure to conduct timely performance reviews and provide the corresponding in‑service education for the identified nurse aides.
Plan Of Correction
Employees E2, E3, E4, E5, and E6 from facility documents given to the survey team will have their annual performance evaluation completed by their Department Manager/DON. The DON/Designee will complete annual evaluations for Nurse Aide on an annual basis. The Administrator will provide education to the facility DON/Designee on the importance of completing Annual Evaluations on the employee in the facility. These evaluations will include Core Values and Objectives, of Quality of Work, Attendance and Punctuality, Communication Skills, Judgement and Decision-making skills Cooperation and Teamwork and Knowledge of position. Audits will be completed by the HR Director/Designee on 10% of Nurse Aide employees each month that the Employee Annual Evaluation has been completed. The results of these audits will be reviewed by the QAPI committee for further recommendations
Failure to Complete Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations at least once every 12 months for three nurse aide personnel records: NA Employee E8, NA Employee E9, and NA Employee E10. Facility policy titled In-Service Training, Nurse Aide, dated 2/11/26, stated that the facility completes a performance review of nurse aides at least every 12 months. Review of the personnel files for NA Employee E8, hired 12/8/20, NA Employee E9, hired 6/5/05, and NA Employee E10, hired 2/21/24, showed that their records did not include annual performance evaluations as required. During interview, the NHA stated that performance evaluations were not being completed because the previous HR person was not completing staff education correctly, and that evaluations were done for everyone in March. The NHA confirmed that the facility failed to complete annual performance evaluations at least once every 12 months for these three nurse aide personnel records.
Failure to Complete CNA Annual Performance Reviews
Penalty
Summary
The facility failed to complete annual CNA performance reviews for 3 of 5 sampled nursing assistants reviewed. Staff H, a CNA hired on 04/09/2025, had no annual performance review completed when the record was reviewed on 04/09/2026. Staff I, a CNA hired on 04/25/2024, had an annual performance review completed on 09/17/2025, which was 5 months past the annual review date. Staff J, a CNA hired on 06/20/2024, had an annual performance review completed on 09/17/2025, which was 3 months past the annual review date. On 04/09/2026 at 12:38 PM, the DON said annual performance reviews needed to be completed and pointed to a binder showing CNA annual performance reviews that needed to be completed. When shown the listed staff without or past due annual performance reviews, the DON said the annual performances were completed within the year, and it was explained that the regulation is based on hire date and hire anniversary rather than calendar year.
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