Failure to Conduct Annual CNA Competency Evaluations
Summary
The facility failed to complete annual performance reviews for Certified Nurse Assistants (CNAs) by not conducting the Annual Core Clinical Competencies (ACCC) assessments. This deficiency was identified through interviews and record reviews, revealing that three out of five CNAs had not been evaluated for their competencies annually. The facility lacked a system to track the CNAs' performance evaluations, which could potentially result in residents not receiving quality care from CNAs with insufficient skills and competencies. The facility's tracking log did not indicate which CNAs required training, and there was no system in place to ensure that the ACCC was completed or up to date. Interviews with the Registered Nurse (RN) and the Director of Staff Development (DSD) confirmed that CNAs were supposed to have yearly clinical skills competency checks. However, the DSD, who had been in the position for eleven weeks, admitted to not having a system to log and track the CNAs' ACCC. Additionally, the Infection Control Nurse (IPN) conducted an in-person lesson in July and August 2023, which was considered an annual ACCC, but not all skills listed in the facility's CNA Core Clinical Competencies were included. The facility's policy and procedure required competency evaluations upon hire, annually, and as deemed necessary, but these were not consistently conducted.
Penalty
Resources
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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 did not complete required annual performance evaluations or skills check-offs for two CNAs, as confirmed through employee file review and staff interviews. Administrative staff acknowledged that annual evaluations were expected but could not produce any evaluation documents for these CNAs, nor could the facility provide a policy outlining annual performance evaluation requirements when requested by surveyors.
The facility failed to complete required annual performance evaluations for two CNAs as mandated by its own performance evaluation policy, which requires a review at the end of probation and at least annually thereafter. Record review showed that both CNAs, employed for multiple years, lacked a documented annual evaluation for the review year, and one CNA reported only receiving paperwork related to pay changes without feedback on job performance. The HR manager acknowledged that the evaluations had been started by a prior DON but not completed, and the NHA stated she expected staff to receive annual performance evaluations.
Surveyors found that the facility did not complete required annual performance reviews or provide related in‑service education for multiple LNAs. Review of several personnel files showed no documented performance evaluations for the most recent year, despite hire dates spanning multiple years. In an interview, the Administrator confirmed that the current year’s employee reviews had not been completed.
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.
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
Missing Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance reviews at least once every 12 months for two CNAs, which is required to ensure adequate and appropriate care and services for residents. On 04/08/26 at 3:52 PM, review of employee files showed there were no performance evaluations or skills check-off documents for CNA OO, hired on 11/10/23, and CNA PP, hired on 07/29/24. Later that day, Administrative Staff A and Administrative Nurse D confirmed that the evaluation documents provided to the survey team did not include performance evaluations for these two CNAs, and Administrative Staff A stated she expected performance evaluations to be performed annually. The facility was unable to provide a policy related to annual performance evaluations when requested on 04/09/26, further demonstrating that there was no documented process in place to ensure that CNAs received regular performance reviews and skills assessments as expected.
Failure to Complete Required Annual Performance Evaluations for CNAs
Penalty
Summary
The deficiency involves the facility’s failure to complete required annual performance evaluations for certified nursing assistants (CNAs) in accordance with its own Performance Evaluations policy dated 9/2020, which states that each employee’s job performance shall be reviewed and evaluated at least annually following a 90‑day probationary evaluation. Record review showed that CNA U, hired on 1/28/15, did not have an annual performance evaluation completed for 2025, and CNA H, hired on 8/21/19, also did not have an annual performance evaluation completed for 2025. During interview, CNA H reported not recalling having a performance evaluation and stated they only received paperwork related to whether there was a raise, without information about job performance. The Human Resources Manager stated that the 2025 evaluations for CNA U and CNA H had been started by the prior DON but were not completed, and acknowledged that an annual evaluation is required. The Nursing Home Administrator stated she would expect staff to have an annual performance evaluation. No resident-specific medical histories or conditions are mentioned in the report, and the deficiency centers on the facility’s noncompliance with its policy and regulatory expectations for annual CNA performance reviews.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and provide regular in‑service education based on those reviews for all four sampled nurse aides. Record review of four employee files showed that one LNA hired in October 2024, another hired in July 2023, a third hired in July 2025, and a fourth hired in December 2018 had no documented performance reviews for 2025 in their personnel files. During an interview on 3/25/26 at 2:40 PM, the Administrator confirmed that the 2025 employee performance reviews had not been completed, corroborating the lack of documentation found in the employee records.
Failure to Complete Annual CNA Evaluations and Full Background Screening
Penalty
Summary
Surveyors identified that the facility did not ensure required annual performance evaluations were completed and properly documented for two of four CNAs reviewed, and did not complete a full pre-employment background check for one CNA. Personnel file review showed CNA 2, hired on 9/28/23, had a performance evaluation dated 9/28/24 but no evaluation for 2025, and the existing evaluation lacked supervisor comments regarding new goals, objectives, and commitments. CNA 4’s performance evaluation was dated 7/20/25, although the CNA’s hire date of 6/1/19 indicated the annual evaluation was due on 6/1/25, and this evaluation also lacked supervisor comments on new goals, objectives, and commitments. During interview, the DSD confirmed there was no 2025 performance evaluation for CNA 2 and stated that performance evaluations should be completed annually and that annual reviews of CNA skills are important to ensure safe resident care. Record review further showed that CNA 4’s personnel file did not contain a full background check as required by facility policy. The file only included a 7-year criminal court record search for Los Angeles County and lacked documentation of an abuse registry check and an exclusion list database check, including the OIG LEIE. Facility policies titled “Background Screening Investigations,” “Hiring,” “Staff Development Program,” and “Performance Evaluations” indicated that background and criminal checks must be initiated within two days of an employment offer and completed prior to employment, including checks of the state nurse aide registry and applicable licensing boards, and that each employee’s job performance must be reviewed at least annually. The policies also stated that CNAs must complete at least 12 hours of annual in-service training to ensure continuing competency and address weaknesses identified in performance evaluations and the facility assessment.
Failure to Complete Required Annual Performance Evaluation for CNA
Penalty
Summary
The facility failed to ensure an annual performance evaluation was up to date for one of five sampled CNAs, as required by facility policy. During an interview and concurrent record review with the Director of Staff Development (DSD), the CNA’s personnel file, initiated on 8/10/20, showed that the last documented annual performance review was completed on 12/28/24, and the DSD confirmed that no annual performance evaluation had been conducted for 2025. Review of the facility’s undated Performance Evaluations policy indicated that each employee’s job performance shall be reviewed and evaluated at least annually, and that completed evaluations are to be sent by the director or supervisor to the HR Director for placement in the employee’s personnel record. The surveyor determined that this lapse had the potential to result in the CNA providing care that does not meet residents’ needs. No additional resident-specific clinical information or medical history was provided in the report related to this deficiency.
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