Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for five nurse aides, identified as NA Employees E11, E12, E13, E14, and E15. These employees were hired on July 1, 2023, and their personnel records lacked the required annual performance evaluations. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 13, 2025, who acknowledged the facility's failure to conduct the evaluations as mandated by the regulations.
Plan Of Correction
Annual performance evaluations were completed for nurse aide employees. The Director of Nursing (DON)/designee reviewed employee files for current nursing assistants to ensure annual performance evaluations are completed. Negative findings will be addressed. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated NHA/DON/HR on regulatory requirements of F730. To monitor and maintain ongoing compliance, the DON/designee will audit employee files for performance evaluations weekly x4 then monthly x2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.