Failure to Complete Annual Performance Appraisals
Summary
The facility failed to complete annual performance appraisals for two nurse aides, NA #10 and NA #11. NA #10's last performance appraisal was not dated by either the nurse aide or the next level manager, while NA #11's last performance appraisal was dated five years ago. The Administrator acknowledged the lapse, attributing it to inconsistent staffing and multiple changes in the Director of Nursing (DNS) position. The current DNS was attempting to catch up on tasks left incomplete by previous staff. According to the facility's policy, managers are required to conduct performance appraisals or performance-based conversations with employees at least annually, and in-service education should be provided based on these reviews.
Penalty
Resources
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Facility staff did not complete annual performance evaluations for two certified nursing assistants, as confirmed by the DON during interviews and document review. The facility was also unable to provide a policy on staff training and performance evaluations when requested.
Annual performance reviews for four out of five CNAs were not completed as required, with administrative staff unable to clarify responsibility for ensuring timely reviews. Facility policy mandates annual review of employee training and attendance records, but this process was not followed for several CNAs.
Facility staff did not complete the required annual performance evaluation for a CNA, and could not provide documentation of this evaluation when requested by surveyors. Administrative staff cited a recent facility sale and lack of access to old personnel records as reasons for the missing documentation.
Annual performance reviews were not completed for three CNAs hired within the past year. The HR assistant identified staff due for review and provided forms to unit managers, but the reviews were not documented or completed as required. The facility's training policy also lacked information on performance reviews.
Certified Nurse Aides did not receive annual performance evaluations or regular in-service education based on those reviews, as confirmed by personnel file reviews and staff interviews. The Administrator attributed this lapse to frequent changes in nurse management, resulting in missed competency assessments and training opportunities.
The facility failed to conduct timely annual performance reviews for a CNA, as required by policy. The CNA was hired in June 2022, but the first evaluation was only completed in January 2025, after surveyor intervention. The DON acknowledged the importance of these evaluations for monitoring performance and discussing improvement areas. The issue was discussed with facility leadership.
Failure to Complete Annual Performance Evaluations for C.N.A.s
Penalty
Summary
Facility staff failed to complete annual performance evaluations for two out of five reviewed certified nursing assistants (C.N.A.s). Specifically, there was no evidence of annual performance reviews for C.N.A.s hired on 7/22/1986 and 11/29/2022. During staff interviews, the Director of Nursing acknowledged responsibility for ensuring annual evaluations and confirmed that evaluations for these two C.N.A.s had not been completed, although evaluations for the other three reviewed C.N.A.s were provided. Additionally, when requested, the facility was unable to present a policy on staff training and performance evaluations. No further information or documentation was provided by facility leadership regarding this concern.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
Facility staff failed to complete annual performance reviews for four out of five certified nursing assistants (CNAs) as required. Specifically, the performance reviews for these CNAs were not conducted on an annual basis according to their hire dates. The director of nursing, who was newly appointed and had no prior experience in the role, was unaware of who was responsible for ensuring the completion of CNA performance reviews. The facility's policy requires that employee attendance and completion records for mandatory in-service trainings be reviewed at least annually, typically at the time of the performance review. No additional information or documentation was provided to address this concern prior to the survey exit. Staff interviews and facility document reviews confirmed the deficiency, with administrative staff unable to clarify responsibility for the process, resulting in missed or delayed annual reviews for multiple CNAs.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
Facility staff failed to complete an annual performance evaluation for one of five certified nursing assistants (CNA) whose records were reviewed. Specifically, there was no evidence that the required annual performance evaluation for CNA #5 had been conducted within the past 12 months. When the survey team requested the most recent performance evaluation for this CNA, administrative staff members, including the executive director and the director of clinical services, indicated that they might not be able to provide the requested documentation due to a recent sale of the facility and lack of access to previous personnel records. The assistant director of clinical services, who was new to the role, confirmed she could not explain why the evaluation had not been completed in a timely manner.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
Facility staff failed to complete annual performance reviews for three certified nursing assistants (CNAs) who were hired in the previous year. Specifically, no annual performance reviews were available for CNAs hired on 11/1/23, 10/10/23, and 10/23/23. The human resources assistant reported that she generates monthly reports to identify staff due for annual reviews and provides blank review forms to unit managers, who are responsible for completing them. However, the required reviews for these three CNAs were not completed, and the facility could not provide documentation of the reviews. Additionally, the facility's policy on training requirements did not include information regarding performance reviews.
Failure to Provide Timely CNA Performance Reviews and In-Service Education
Penalty
Summary
Certified Nurse Aides (CNAs) at the facility did not receive required performance evaluations at least once every 12 months, nor did they receive regular in-service education based on the outcomes of such reviews. Personnel files for four CNAs showed no documented evidence of performance evaluations or related in-service education, despite their employment ranging from several months to over a year. Interviews with additional CNAs revealed that some had not received performance reviews or competency training since starting at the facility, with one CNA stating she had only received one performance review in three years and never received competency training. The Administrator confirmed that due to multiple changes in nurse management, the facility had not completed competencies and performance evaluations for CNAs. This lack of regular performance assessment and training was identified through interviews and record reviews, and it was noted that this had the potential to negatively impact resident care.
Failure to Conduct Timely Annual Performance Reviews for CNA
Penalty
Summary
The facility staff failed to conduct annual performance reviews for a certified nursing assistant (CNA #14) as required. CNA #14 was hired on June 12, 2022, and the first evaluation in her record was completed on January 27, 2025, which was after the surveyor had requested the employee files. This indicates that the annual evaluation was not conducted in a timely manner. During an interview, the Director of Nursing (DON) acknowledged that the purpose of the annual evaluations was to monitor the employee's performance and discuss areas needing improvement. The facility's policy on performance evaluations states that these evaluations provide a formal opportunity for supervisors and employees to discuss work performance and developmental areas related to the job description. The deficiency was discussed with the administrator, regional vice president of operations, and the DON during an end-of-day meeting.
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