Failure to Conduct Annual Performance Reviews and Individualized Training
Summary
The facility failed to conduct annual performance reviews for four nursing assistants, identified as NA-A, NA-F, NA-B, and NA-E. This deficiency was discovered through interviews and document reviews, which revealed that none of these nursing assistants had evidence of completed annual performance reviews in their personnel records. NA-A and NA-F, who were hired in 2023, along with NA-B and NA-E, hired in 2018 and 2021 respectively, all lacked documentation of such reviews. This failure to conduct performance reviews also meant that the facility did not provide individualized training based on any identified areas of weakness from these reviews. Interviews with the nursing assistants and a registered nurse further confirmed the lack of awareness and implementation of performance-based training. NA-B, NA-E, and NA-A all reported only completing the standard annual computer training required for all employees, with no additional individualized training. The registered nurse, RN-A, also stated he was unaware of any training based on performance reviews. The facility administrator, who was new, admitted to not being aware of any completed performance reviews or specific training processes. Additionally, a policy on performance reviews and training was requested but not provided, indicating a possible lack of established procedures in this area.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not ensure that two CNAs completed the required 12 hours of annual continuing education, with both having only five hours documented for the year. This lapse was confirmed by the HRM and had the potential to impact all residents in the facility.
The facility did not ensure that its CNAs received the mandated 12 hours of annual in-service training, with records showing only 4.5 hours completed within the first year of employment and no evidence of prior training. This deficiency had the potential to impact all 79 residents, as essential education in dementia care and abuse prevention was not documented.
The facility did not ensure that two CNAs completed the federally required 12 hours of annual in-service training, as confirmed by missing documentation in their education files. This deficiency was identified during a review of employee records and verified by the staff responsible for medical records, potentially impacting all residents.
The facility did not ensure that CNAs received the required 12 hours of annual in-service training. Instead of regular training, staff were given a packet of materials to review on their own, with no system to track completion or understanding. This affected all residents in the facility.
A CNA did not complete the required 12 hours of annual continuing education, with only 6.25 hours documented over a 19-month period. Facility policy and training practices allowed for gaps exceeding 12 months without meeting education requirements, and the policy lacked specific details on the 12-hour mandate.
A CNA failed to complete the required annual in-service education, attending only three out of twelve sessions, missing key topics such as abuse prevention and communication. Two residents with intact cognition reported or witnessed disrespectful treatment by this CNA, though no abuse was alleged. The incomplete training and reported conduct had the potential to affect all residents.
Failure to Ensure Required CNA Continuing Education
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required annual continuing education hours. Specifically, a review of personnel files showed that one CNA, hired in December 2022, had completed only five hours of continuing education for the 2024 calendar year, and another CNA, hired in February 2023, also had only five hours completed for the same period. Interviews with the Human Resources Manager confirmed that both CNAs had not met the required 12 hours of annual continuing education. This deficiency had the potential to affect all 67 residents in the facility, as it involved non-compliance with mandated training requirements for CNAs.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that its certified nurse aides (CNAs) received the required 12 hours of in-service training per year. Personnel records for two CNAs showed that each received only 4.5 hours of in-service training within their first year of employment, and all of these hours occurred in the following calendar year. There was no evidence of any in-service education provided to CNAs prior to that year. This deficiency was confirmed during an interview with the Administrator, who acknowledged the lack of required in-service hours for the CNAs in question. This lapse in training had the potential to affect all 79 residents in the facility, as the required education in dementia care and abuse prevention was not documented as completed for the CNAs reviewed.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of in-service training annually, as mandated by federal regulations. During a review of employee files, it was found that two CNAs did not complete the annual in-service training hours. Specifically, the education files for these CNAs did not contain documentation showing completion of the required training for the relevant years. An interview with the staff member responsible for medical records confirmed that there was no documentation available to verify that the two CNAs had completed the 12-hour in-service requirement for the specified years. This deficiency was identified through a review of three CNA files, with two found to be non-compliant, potentially affecting all residents in the facility, which had a census of 39 at the time.
Plan Of Correction
Tag: F 0947 All nurse aides (#510 and #519) identified during the survey who had not completed the required 12 hours of in-service training for calendar year 2025 were immediately scheduled for and have now completed the missing training, including dementia care and abuse prevention modules. A facility-wide audit of all nurse aide training records for the past 12 months was conducted to identify any additional staff who were out of compliance with the annual in-service requirements. Any additional deficiencies found have been corrected as of 6/25/25. The administrator provided training to the HR director on 6/16/25 regarding requirements of CNAs to complete 12 CEUs annually. HR or designee will audit monthly for the next 3 months. Results of the audit will be provided to the QAPI committee for review and recommendation.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to provide regular annual training for certified nursing assistants (CNAs), as required for their 12 hours of in-services each year. Review of personnel files for three CNAs showed no evidence of ongoing training throughout the year. Instead, the facility discontinued its online training program over a year ago and began giving staff a packet of in-service materials for the entire year at orientation and annually, with only the first page signed by the employee. There was no system in place to track or verify that staff actually read or completed the training materials, as confirmed by the Human Resource Director. This lack of regular and verifiable training had the potential to affect all 111 residents in the facility.
Failure to Ensure Required Annual Continuing Education for CNA
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA) completed the required 12 hours of continuing education within a 12-month period, as evidenced by a review of personnel files and training logs. The CNA in question had only completed 6.25 hours of continuing education over a 19-month period, with training sessions spread out and not meeting the annual requirement. An interview with the Human Resources staff confirmed that the facility's practice of using a rolling calendar for training could result in staff going more than 12 months without completing the necessary education. Additionally, the facility's policy on training and staff development did not specify the requirement for 12 hours of continuing education per year.
Failure to Ensure Required CNA In-Service Education and Respectful Resident Treatment
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA) completed the required minimum of twelve hours of in-service education annually, as mandated. Review of CNA #22's employee file showed that only three out of twelve required in-service sessions were attended in the previous twelve months, totaling just three hours of education. The missed in-services included critical topics such as resident rights, infection control, code of conduct compliance and ethics, emergency preparedness, elopement, customer service with a person-centered approach, first aid basics, behavior management, communication and conflict resolution, and abuse and neglect. This deficiency was confirmed by the Business Office Manager, who verified the incomplete training record. Interviews with two residents, both with intact cognition and relevant psychiatric diagnoses, revealed concerns regarding CNA #22's conduct. One resident reported being treated in a disrespectful manner by CNA #22, though she did not feel threatened. Another resident witnessed the same CNA treating the first resident in an undignified and disrespectful way, describing the behavior as disrespectful but not abusive. These findings, combined with the incomplete in-service education, had the potential to affect all 56 residents in the facility.
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