Failure to Complete Annual Performance Reviews for Nurse Aides
Summary
The facility failed to ensure that annual performance reviews for nursing staff were completed at least once every 12 months, as required by their policy. Specifically, the facility was unable to provide annual performance reviews for two Certified Nurse Aides. The facility's policy, revised in December 2014, mandates routine and periodic appraisals of job performance and competencies for each employee, with evaluations conducted annually. During interviews, the Director of Human Resources acknowledged that departments were responsible for completing these appraisals and that notifications and reminders were sent via email and during morning reports. However, they could not explain why the appraisals for the two Certified Nurse Aides were not completed. The Administrator noted that there were shortcomings in completing annual performance appraisals during 2023-2024 due to the human resource director position being a corporate shared role rather than a dedicated role for the facility.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the staff found to have been affected by the deficient practice is: The DON and/or designee will ensure that all nursing employees affected by the deficient practice receive an annual performance review for the period under review 2024. 2. How will you identify other staff as having the potential to be affected by the same deficient practice what corrective action will be taken? The DON and/or designee will ensure that all nursing employees receive an annual performance review for the period under review 2024. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? A list of all C.N.As on all shifts will be distributed via email to all nurse managers and nursing supervisors to ensure that all required nursing staff receive an annual performance review. All nursing supervisors will receive email notification to remind them that annual performance evaluations are due. The DON and/or designee will track and monitor compliance with completion of annual performance reviews for nursing staff. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e., what program will monitor the continued effectiveness of the systemic change)? A tracking list will be utilized to validate that all evaluations are completed and submitted to HR. The tracking will be audited weekly for one month, then monthly for three months. The results of the audits will be submitted to the Administrator and results of the audits will be reported to the QAPI committee monthly by the Director of Nursing for three months to the QAPI committee for action as appropriate.
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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