Failure to Conduct Timely CNA Performance Reviews
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance reviews were conducted at least once every 12 months, as required. Specifically, three CNAs, hired in 2017, 2018, and 2020, did not have documented performance reviews within the last 12 months. During interviews, the Human Resource Director acknowledged that unit supervisors were responsible for completing these reviews and that they should be filed in employee folders. However, the director was unaware that the reviews for these CNAs had not been completed. The Assistant Administrator was also unsure why the reviews were not conducted, and the Assistant Director of Nursing, who had previously assisted with these reviews, believed they had been completed. This deficiency was identified during a recertification survey conducted from February 10 to February 14, 2025.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 F730 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: - The performance reviews for Certified nurse aide #2, #3, #4 were completed on 2/17/25. The human resource director audited all current Certified nursing assistants to ensure performance reviews in place. No additional occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Director of nursing and administrator reviewed staff performance review policy with no revisions needed. - The Director of human resources was educated on criteria that performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews. - The director of Human Resources/ designee will audit every 2 weeks for employees eligible for performance reviews to ensure they are completed per specifications x 1 month, then monthly x 3 months. - The director of Human Resources/ designee will keep a running log of all certified nursing assistants eligible for performance review and ensure they are filed in employee folders once completed. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. - The Director of Human Resources/ designee will audit every 2 weeks for employees eligible for performance reviews to ensure they are completed per specifications x 1 month, then monthly x 3 months. - Any discrepancies will be reported to administrator and immediately corrected. - The results of the Audit will be reported at monthly QAPI.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Annual CNA Performance Reviews: The facility failed to complete annual performance reviews for 3 of 3 CNAs whose personnel files were reviewed. During file review, CNAs #2, #3, and #4 were found to have no performance review documentation since 2024, and the HR Director stated no CNA performance reviews had been done since 2024 because the process was being revised.
The facility failed to complete annual performance reviews for 3 CNA staff members reviewed for sufficient and competent nurse staffing. Personnel record review showed the CNAs did not have completed evaluations, and the Administrator and DNS confirmed the missing reviews.
The facility failed to complete annual performance reviews for 2 nurse aides and failed to provide completed competency checklists for a mechanical lift for 2 CNAs. A resident with severe cognitive impairment and a care plan requiring 2-person mechanical lift transfers fell during a lift when the sling was improperly placed, resulting in a head injury that required stitches and CT imaging. Interviews showed the CNAs were transferring the resident when the fall occurred, and facility leaders stated improper lift use and incomplete competency documentation could lead to serious injury.
Incomplete CNA In-Service Training and Performance-Based Education: Record review showed the facility failed to ensure all CNA staff received the required annual in-service hours and education based on performance reviews. Five CNAs lacked the required 12 hours of in-service training, and an administrative nurse stated she could not locate the documentation or provide the needed hours for staff. The facility’s program required regular in-service classes, annual performance reviews, and training to address identified weaknesses.
Missing CNA Annual Training and Performance Review Documentation: Record review and staff interview showed the facility failed to ensure 1 of 3 CNAs had documentation of the required 12 hours of annual in-service training and a performance review. The Administrator confirmed the missing records after a request was made for CNA education and performance review files.
Missing Annual CNA Performance Evaluation: The facility failed to document an annual performance review for one CNA. Review of the employee file showed no evaluation for the prior year, and the DSD confirmed the required hire, 90-day, and annual evaluations had not been completed or documented. The DON stated annual evaluations are used to identify strengths and weaknesses and support staff competency, and the facility policy required a formal written evaluation annually.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure annual performance reviews were completed at least once every 12 months for 3 of 3 CNAs (#2, #3, and #4) whose personnel records were reviewed for sufficient and competent CNA staffing. During review of CNA employee personnel files on 6/9/26 at 11:00 AM, it was observed that CNAs #2, #3, and #4 had no performance review documentation since 2024. At 11:10 AM, the HR Director stated the facility had not conducted any CNA performance reviews since 2024 because the process was being revised.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed for 3 of 3 sampled CNA staff reviewed for sufficient and competent nurse staffing. A review of personnel records on 6/5/26 showed that Staff 11, hired in 12/2019, Staff 12, hired in 8/2013, and Staff 13, hired in 1/2019, did not have completed performance reviews. On 6/4/26 at 4:00 PM, the Administrator and DNS confirmed that annual performance reviews had not been completed for these three CNA staff members.
Incomplete CNA Competency Review and Mechanical Lift Transfer Injury
Penalty
Summary
The facility failed to complete annual performance reviews for 2 of 4 nurse aides reviewed, and it also failed to provide completed competency checklists for use of the mechanical lifting device for CNA A and CNA C. The report states that the competency assessment for the mechanical lift was done by the ADON in March 2026, but the records did not include employee names, titles, signatures, IDs, initials, or completed dates, and the facility did not provide properly completed documents showing that any employee had taken the competency assessment and in-service before the resident injury. Resident #27 was admitted with multiple diagnoses including atherosclerotic heart disease, violent behavior, dementia, depression, gait and mobility abnormalities, lack of coordination, and cognitive communication deficit, and had a BIMS score of 00 indicating severe cognitive impairment. The care plan required assistance by 2 staff with mechanical lift transfers and staff assistance with bathing/showering. On 06/01/2026, video evidence showed Resident #27 falling from the mechanical lift due to improper placement of the sling strap, and the resident sustained a head injury that required stitches and CT imaging of the brain and neck. During interviews, CNA C stated that he and CNA A were transferring Resident #27 with a mechanical lift when the resident fell, and that the sling was improperly placed. CNA C stated the resident was not centered in the lift and that both staff were responsible for ensuring proper positioning. CNA A stated the resident was moving during the transfer and that she did not pause or ask for help. The ADON, DON, LVN A, and ADM each stated that improper use of the mechanical lift and incomplete competency documentation could lead to serious injury, and the facility policy on mechanical lifting devices described safe lifting principles using the device.
Incomplete CNA In-Service Training and Performance-Based Education
Penalty
Summary
The facility failed to provide regular in-service education based on the outcome of performance reviews and failed to ensure that all nurse aides received the required number of in-service training hours per year. Record review showed the facility employed eleven nurse aides for at least one year, and in-service records showed that 5 of the nurse aides reviewed had not completed the required 12 hours of in-service training in the past year. The records identified CNA N, CNA O, CNA P, CNA Q, and CNA X as lacking the required number of in-service hours and the in-services based on performance evaluations. The report also noted that the Social Service Director and CNA X were among those without the required in-service documentation. On interview, Administrative Nurse D stated she had been employed at the facility for approximately six weeks and was unable to find the documentation and failed to provide the hours needed by the nurse aide staff. The facility's In-Service Training Program, Nurse Aide, dated May 2021, stated that nurse aides would participate in regularly scheduled in-service training classes, that performance reviews were completed at least every 12 months, and that in-service training was based on the outcome of annual performance reviews and addressed areas of weakness.
Missing CNA Annual Training and Performance Review Documentation
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service training and performance reviews. Record review and staff interview showed this was true for 1 of 3 CNAs reviewed for skills and qualifications. On 5/29/26 at 12:57 PM, a request was made for CNA education records and performance reviews, and on 5/29/26 at 1:50 PM, the Administrator stated that 1 of 3 CNAs did not have documentation of the required 12 hours of annual training or a performance review.
Missing Annual CNA Performance Evaluation
Penalty
Summary
The facility failed to ensure that a performance review for one Certified Nurse Assistant, CNA 9, was completed at least once every 12 months. During a concurrent interview and record review with the Director of Staff Development, CNA 9’s employee file dated from 8/2022 to 5/2026 was reviewed and showed no performance evaluation documented for 2025 and no annual evaluation completed as required. The DSD stated that employee performance evaluations are required upon hire, 90 days after hire, and annually thereafter, and confirmed that CNA 9’s performance evaluation had not been conducted or documented. The DON stated that employee performance evaluations should be conducted at least annually to identify strengths and weaknesses in an employee’s skills and to ensure staff are competent to provide appropriate care to residents. The facility’s policy titled Evaluation Process stated that employees are to receive a formal written evaluation annually, with the manager or supervisor completing the evaluation form and forwarding the original evaluation tools to Human Resources for placement in the personnel file.
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