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.
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.
Failure to Complete Annual CNA Performance Evaluation: The facility failed to ensure that one CNA received the required annual performance review per policy. The DSD stated the CNA’s annual evaluation was overdue, and the DON stated evaluations are used to review staff performance, identify strengths and weaknesses, and determine if additional training is needed. The facility policy required formal written evaluations annually after the initial 90-day review.
Surveyors found that two CNAs did not have timely, fully documented annual performance evaluations, and one CNA lacked a complete pre-employment background check. One CNA had no evaluation for the most recent year, and another’s evaluation was completed late; both evaluations lacked supervisor comments on new goals, objectives, and commitments. The same CNA’s file contained only a limited county criminal search without required abuse registry and OIG LEIE exclusion checks, despite facility policies requiring comprehensive background screening and annual performance reviews to support ongoing CNA competency.
Surveyors identified that an annual performance evaluation was not completed for one of five sampled CNAs, contrary to facility policy requiring at least yearly reviews of each employee’s job performance. Review of the CNA’s personnel file with the DSD showed the last evaluation was documented more than a year prior, and the DSD acknowledged that no subsequent evaluation had been done. The facility’s policy also required that completed evaluations be forwarded to HR for inclusion in the personnel record, but no current evaluation was present, creating the potential for the CNA to provide care that may not meet residents’ needs.
The facility did not complete required annual performance evaluations for three CNAs, leaving their personnel records without current assessments of job performance, goals, attendance, and policy adherence. The DSD, who is responsible for CNA evaluations, confirmed that no annual evaluations had been done and acknowledged their importance for ensuring staff competency in providing resident care. The DON also confirmed that these evaluations had not been completed and should have been, noting they are necessary to ensure staff can provide appropriate care and meet residents’ needs. This failure was not consistent with the facility’s written evaluation policy, which requires formal written annual evaluations for employees.
The facility did not complete required annual performance evaluations for two CNAs in accordance with its policy. Both CNAs had their last evaluations documented more than a year earlier, and the HR manager acknowledged that new evaluations should have been completed around their employment anniversary dates. The Administrator confirmed that evaluations are expected yearly, and the written policy states that supervisors must conduct annual performance discussions at or around each employee’s anniversary date, but this was not done, resulting in overdue evaluations.
The facility did not complete required annual performance evaluations for multiple CNAs, as shown by personnel records indicating that several CNAs had no documented reviews for one or more years despite a written policy requiring annual evaluations by supervisors. The DSD confirmed that no CNA performance reviews had been conducted since she assumed her role, even though she acknowledged they should occur yearly. This deficiency was identified through staff interviews and review of employment records and facility policy.
The facility did not complete required annual performance reviews for a CNA, as the CNA’s personnel file showed the last documented review occurred several years after hire with no subsequent evaluations. The DSD confirmed that annual performance reviews are required for all CNAs to ensure they are performing their job, and acknowledged that no more recent review was on file. Facility policy on competency evaluation requires ongoing assessment of employee competencies and skills, including subsequent and/or annual evaluations based on the facility assessment, training program evaluation, and job performance evaluations.
Surveyors found that the facility did not complete required annual competency/skills assessments for two CNAs and lacked documented abuse and dementia training for two other CNAs. One CNA’s last competency review was several months overdue, and another had an unsigned, undated skills checklist with no confirmation of completion. Training files for two additional CNAs lacked evidence of abuse prevention and dementia management education, despite facility policy and the facility assessment requiring annual competency validation and inclusion of dementia and abuse training. The DSD acknowledged these training gaps and that they could affect staff ability to respond to abuse situations and care for residents with dementia.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account