Failure to Conduct Annual Competency Evaluations for RCPs
Summary
The facility failed to conduct annual competency evaluations for five Resident Care Providers (RCPs), identified as RCP L, RCP O, RCP U, RCP V, and RCP W. These evaluations are crucial to ensure that the RCPs are proficient in the care they provide to residents. The personnel file review revealed that none of these RCPs had a competency evaluation on file, despite their hire dates being over a year prior. This oversight was discovered during a record review conducted on February 12, 2025. Interviews with the Director of Nurses and the Administrator revealed a lack of awareness regarding the completion of these evaluations. The Director of Nurses admitted to not knowing if the evaluations had been completed and could not locate them, suggesting that the previous Director of Nurses might not have filed them properly. The Administrator also expressed uncertainty about the completion of the evaluations, although she believed they had been done. The facility's policy requires all nursing staff to meet specific competency requirements and participate in a competency-based staff development program, which was not adhered to in this case.
Penalty
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Two CNAs were found to be actively working without current annual performance reviews, as confirmed by personnel file audits and staff interviews. The DON verified that both CNAs were scheduled and working shifts without the required reviews, potentially affecting all residents in the facility.
Annual evaluations were not completed for several CNAs, as confirmed by personnel file reviews and an interview with the HRM. This lapse had the potential to impact all residents in the facility.
The facility did not complete required quarterly or annual performance evaluations for several CNAs, as confirmed by a review of personnel files and an interview with the HR Manager. This failure had the potential to impact all residents, as regular evaluations are necessary to ensure proper care.
A review of personnel records and staff interviews revealed that CNAs did not receive the required 12 hours of annual in-service training, with no documentation of training dates, topics, or attendance. The facility only provided policies for staff to read, lacking evidence of formal in-service sessions. This deficiency was identified during a complaint investigation and had the potential to impact all residents.
Two CNAs did not receive annual performance evaluations or the required 12 hours of in-service training, as confirmed by personnel file reviews and interviews with the COO. This lack of documentation and training had the potential to impact all 54 residents in the facility.
The facility did not conduct annual performance evaluations for CNAs as required by their policy, affecting all 81 residents. Employee files for two CNAs lacked documentation of evaluations, confirmed by interviews with the Administrator and Employee Experience Manager. The facility's policy mandates evaluations after six months, 12 months, and annually thereafter.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that two out of five reviewed Certified Nursing Assistants (CNAs) received their required annual performance reviews. Personnel file audits revealed that one CNA, hired in September 2020, and another CNA, hired in June 2011, did not have current annual performance reviews on file. Interviews with both CNAs confirmed that their annual reviews had not been completed. The Director of Nursing (DON) also confirmed that these CNAs were actively working scheduled shifts throughout the facility without current annual performance reviews in place. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility, which had a census of 99 at the time of the survey.
Failure to Complete Annual Staff Evaluations
Penalty
Summary
The facility failed to complete annual evaluations for its staff, specifically for three Certified Nursing Assistants (CNAs) whose personnel files were reviewed. The personnel records showed that each of these CNAs had been employed for over a year or close to a year, yet there was no documentation of annual evaluations in their files. During an interview, the Human Resource Manager confirmed that annual evaluations had not been completed for these staff members. This deficiency had the potential to affect all 90 residents residing in the facility, as regular staff evaluations are necessary to ensure quality care.
Failure to Conduct Required CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct required performance evaluations for Certified Nursing Assistants (CNAs), as evidenced by a review of employee files. Personnel files for four CNAs showed no documentation of quarterly or annual performance evaluations, despite their respective hire dates indicating that such evaluations were due. This lapse was confirmed during an interview with the Human Resource Manager, who acknowledged the absence of performance evaluations in the files reviewed. This deficiency had the potential to affect all 64 residents residing in the facility, as regular performance evaluations are necessary to ensure that CNAs are meeting job expectations and providing appropriate care.
Failure to Document and Provide Required CNA Annual In-Service Training
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required minimum of 12 hours of annual in-service training. Personnel records for five CNAs were reviewed, and in each case, there was no documentation showing completion of the mandated annual in-service training hours. The records lacked evidence of in-service dates, times, topics, or attendance, and only included an undated list of CNAs with a note indicating 'Message received' and copies of facility policies. During an interview, the Director of Human Resources confirmed that the facility did not have documentation of in-service training sessions, including dates, times, topics, or attendance records. Instead, CNAs were provided with policies to read, but there was no evidence that formal in-service training was conducted or tracked as required. This deficiency was identified during a complaint investigation and had the potential to affect all 89 residents in the facility.
Failure to Complete CNA Performance Reviews and In-Service Training
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs) received annual performance evaluations and the required 12 hours of in-service training. Review of the personnel files for both CNAs showed no documentation of annual performance reviews or evidence of completed in-service hours. The Chief Operating Officer confirmed during interviews that the facility was unable to provide records of these evaluations or training for the CNAs in question. The facility assessment indicated that areas of weakness identified in nurse aide performance reviews would be addressed through training and in-services, with topics including communication, resident rights, abuse, infection control, culture change, and dementia management. However, the lack of documented performance evaluations and in-service training for the CNAs had the potential to affect all 54 residents residing in the facility.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) received annual performance evaluations as required by their policy. Specifically, the employee files for two CNAs, hired in 2013 and 2024 respectively, lacked documentation of annual performance evaluations. Interviews with the Administrator and the Employee Experience Manager confirmed that if evaluations were not present in the files, they had not been conducted. The facility's policy, dated March 2014, mandates that CNA performance evaluations be completed after six months of service, after 12 months of service, and annually thereafter. This deficiency had the potential to affect all 81 residents residing in the facility.
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