Deficiency in CNA Performance Reviews and In-Service Education
Summary
The facility failed to ensure that a performance review of every nurse aide was completed at least once every 12 months, and that each nurse aide received no less than twelve hours of in-service education per year based on the outcome of these reviews. This deficiency was identified during a survey, which included staff interviews and a review of facility documentation. Specifically, the facility did not conduct timely performance reviews for two Certified Nursing Assistants (CNAs), nor did it provide the required in-service education hours. Certified Nursing Assistant #1 had not received a performance evaluation since May 4th, 2021, and had attended only nine in-services, which did not meet the required twelve hours of education. Additionally, Certified Nursing Assistant #4 had only one performance review on file dated July 6th, 2017, and had attended only three in-services since their hire date. The documentation revealed that Certified Nursing Assistant #1 had a history of verbal counseling in 2024 for issues such as failure to document and improper break time. Certified Nursing Assistant #4 had received warning notices for various infractions, including leaving a resident unattended in a bathroom. Despite these documented issues, the facility did not ensure that these CNAs received the necessary performance evaluations and in-service education to address and improve their job performance. This lack of compliance with regulatory requirements for performance reviews and education contributed to the identified deficiency.
Plan Of Correction
Plan of Correction: Approved December 23, 2024 The three staff members have been terminated based on the findings of the investigation. The facility will audit all current CNAs 12 hours of education and annual performance evaluations. Any CNAs not in compliance with the 12 hours of education or annual performance evaluation will be corrected. Education will be provided to the Director of Human Resources and all CNA staff that 12-hour education is required each year as well as annual performance evaluations. The facility will audit all CNAs 12 hours of education and annual performance evaluations weekly for 3 months, then monthly thereafter to ensure all 12 hours of education and annual performance reviews are in compliance. Any findings of noncompliance will be reported to QAPI. Responsibility: Director of Nursing and Director of Human Resources or Designee
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to complete annual performance evaluations for three nurse aides. Personnel record review showed each aide was hired on 7/1/23, and none of the three files contained the required yearly performance evaluation. The NHA confirmed the missing evaluations during interview.
The facility failed to complete annual performance reviews for three nurse aides reviewed. Record review showed the aides did not have current annual performance reviews in their personnel files, and the NHA confirmed the omission during interview.
A CNA involved in an abuse allegation did not have an annual PE on file, even though the facility's handbook said employees may be reviewed about once per year and the PE should be based on job performance and duties. The CNA was hired in 2024, but the DSD and VPHR could not locate the required evaluation during record review. The case involved a resident with HTN, anxiety, and adult failure to thrive who had severely impaired cognition and no decision-making capacity; an SBAR and IDT note documented an allegation that the CNA tapped the resident on the lips and acted aggressively during care, which the CNA denied.
Missed Annual CNA Performance Reviews: The facility failed to complete required annual performance reviews for 5 CNAs. HR stated reviews were delayed while the union worked on new wage rates and that prior reviews could not be located. The DON stated annual reviews were expected and many were overdue.
A facility failed to complete an annual performance evaluation for a CNA whose file showed the last evaluation was in 2012. The CNA was linked to a resident complaint of being smacked on the hand and a family member’s complaint about the CNA’s care. One resident had hemiplegia, hemiparesis, osteoarthritis, and depression and needed extensive ADL assistance, while another resident had dementia, hepatic failure, spinal stenosis, and severe cognitive impairment with dependence for all ADLs.
Missing Annual CNA Performance Reviews: The facility did not complete yearly performance reviews for 5 of 5 CNAs reviewed. Record review showed each CNA lacked a performance evaluation within the past 12 months, and the NHA acknowledged that the annual reviews were not completed.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations at least once every 12 months for three of three nurse aide personnel records, including NA Employee E23, NA Employee E24, and NA Employee E25. Review of each personnel file showed a date of hire of 7/1/23, and each record lacked an annual performance evaluation at least every 12 months as required. During an interview on 8/4/26 at 1:55 p.m., the Nursing Home Administrator confirmed that the facility failed to complete the required annual performance evaluations for all three nurse aides.
Missing Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews at least once every 12 months for three of three nurse aides reviewed: Employee E13, Employee E14, and Employee E15. Review of facility documentation and employee personnel files showed that these nurse aides did not have completed, up-to-date annual performance reviews. During an interview on July 30, 2026, at 2:30 p.m., the Nursing Home Administrator, Employee E1, confirmed that the facility had failed to complete annual performance reviews for Employees E13, E14, and E15. The cited regulatory references were 28 Pa. Code 201.14(a) and 28 Pa. Code 201.19(2).
Missing Annual Performance Evaluation for CNA Involved in Abuse Allegation
Penalty
Summary
The facility failed to ensure that one sampled CNA involved in an allegation of staff-to-resident abuse received a performance evaluation at least once every 12 months, as required by the facility's Employee Handbook. The deficiency involved CNA 1, who was hired on 8/27/2024 and whose annual performance evaluation should have been completed in 8/2025, but could not be found in the employee personnel file, HR records, or by the DSD and VPHR during the survey review. Resident 1 was admitted to the facility with diagnoses including HTN, anxiety disorder, and adult failure to thrive. The resident's MDS dated 6/11/2026 indicated severely impaired cognitive skills for daily decision making and the need for substantial/maximal assistance with ADLs. A later H&P dated 7/19/2026 stated the resident did not have decision-making capacity. On 7/22/2026, an SBAR documented an allegation that a student reportedly saw CNA 1 tap Resident 1 on the lips after the resident used profanity during care, and that CNA 1 acted aggressively toward the resident. The IDT conference dated 7/23/2026 documented an allegation of physical abuse and noted the resident had no injuries or signs of distress. During interview, CNA 1 denied touching or tapping the resident's mouth, denied being rough or aggressive, and denied grabbing the resident by the neck during transfer. The DSD, VPHR, and DON all confirmed that no performance evaluation for CNA 1 could be located and stated that annual evaluations were expected based on the employee's hire date and were intended to review performance and areas for improvement.
Missed Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for 5 of 5 CNAs identified in the report: Staff M, Staff N, Staff O, Staff P, and Staff Q. The facility’s staff list showed that Staff M, Staff N, Staff O, Staff P, and Staff Q had been hired 22 months, 16 months, 63 months, 23 months, and 23 months before survey, respectively. No documentation was provided to show performance reviews were completed for Staff M, Staff N, Staff O, or Staff P. Staff Q had one Employee Performance Review dated 11/27/2025, which was 15 months after hire, and no other performance review documentation was provided. During interview, Human Resources stated the facility was waiting to complete annual performance reviews because the employee union was still working on new wage rates, and that performance reviews were required every 12 months but had not been done because employees wanted to know how the reviews would affect their wages. The Human Resources staff also stated they could not locate prior performance reviews for the listed staff. The DON stated that annual performance reviews were expected and that many were overdue.
Missing Annual Performance Evaluation for CNA with Resident Complaints
Penalty
Summary
The facility failed to complete an annual performance evaluation for CNA 6, whose personnel file showed the last documented performance evaluation was in 2012. The facility’s policy titled Performance Evaluations, revised 2/2026, stated that the job performance of every employee was to be reviewed and evaluated at least annually. During interview, the Interim DON confirmed the missing evaluation and stated that performance evaluations were important to identify what staff were lacking and what areas of improvement needed to be addressed. The deficiency involved CNA 6 while there were resident complaints and allegations involving that aide. Resident 8’s record showed a readmission with diagnoses including hemiplegia, hemiparesis following cerebral infarct, osteoarthritis, and depression, and the MDS indicated the resident could make herself understood and understand but needed supervision with eating and was dependent on staff for oral hygiene, toileting hygiene, dressing, showering, and personal hygiene. Resident 8 reported in an SBAR form that CNA 6 smacked her on the right hand, and later stated the aide smacked her and pointed to her right wrist. In addition, Resident 11’s family member stated they did not want CNA 6 to care for Resident 11 and was unsatisfied with CNA 6’s work; Resident 11’s record showed diagnoses including hepatic failure, lumbar spinal stenosis, dementia, and cataract, and the MDS indicated severely impaired cognition and dependence for all ADLs.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility did not complete performance reviews for CNAs at least every 12 months for 5 of 5 CNAs reviewed: CNA3, CNA4, CNA5, CNA6, and CNA7. The facility’s policy, Job Descriptions and Performance Evaluations, dated 9/20, states that performance evaluations measure standards against job performance and are intended to aid management in analyzing and improving the facility’s services and structure and to improve the quality of work performance. Record review showed CNA3, hired 2/16/25, did not have a yearly performance review completed in the last 12 months; CNA4, hired 9/21/09, did not have a yearly performance review completed in the last 12 months; CNA5, hired 5/23/25, did not have a yearly performance review completed in the last 12 months; CNA6, hired 1/13/20, did not have a yearly performance review completed in the last 12 months; and CNA7, hired 12/31/97, did not have a yearly performance review completed in the last 12 months. On 7/27/26 at 12:40 PM, the NHA stated the facility did not have yearly performance reviews for the CNAs and acknowledged that the reviews should have been completed.
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