Deficiency in CNA In-Service Training Hours
Summary
The facility failed to ensure that five randomly selected Certified Nurse Aides (CNAs) received the required 12 hours of annual in-service education. Specifically, CNAs #17, 18, 19, 20, and 21 only received 10 hours of training, which did not include mandatory topics such as abuse and residents' rights. This deficiency was identified during a recertification survey conducted from March 5 to March 12, 2025. The Director of Nursing confirmed the shortfall in training hours during an interview on March 11, 2025. The Administrator acknowledged the deficiency, attributing it to a lapse in monitoring due to turnover in the Assistant Director of Nursing position. The facility had two Assistant Directors of Nursing who did not remain employed, leading to a failure in ensuring the CNAs met the 12-hour in-service requirement. Both the Administrator and the Director of Nursing were aware of the deficiency by the end of the survey, recognizing that the CNAs had not completed the necessary training hours or covered the required topics.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 F730 P(NAME) Description: I. Immediate Corrective Action All C.N.A’s will be educated via in-service on resident abuse and resident rights. All 5 CNAs reviewed have been provided with additional in-services to equal the required 12 hours/annually. II. Identification of others A. All residents have the potential to be affected. The DNS/designee will review all CNA records to ensure that all CNA’s have received the mandatory in-services within the past year as well as 12 hours of in-service/year. Those found not to have these in-services will immediately be scheduled for in-services which will be provided by the DNS/designee. III. Systematic Changes The DNS/administrator reviewed the policy and procedure on C.N.A. yearly in-service and found it to be in compliance. IV. QA monitoring a. An audit tool was developed by the DON to ensure that all C.N.A’s are receiving the 12 hours of in-service annually specifically abuse and resident rights. b. Audits will be conducted weekly for 4 weeks on randomly selected CNAs and then monthly for 11 months. Any negative findings from the audits shall be reported to DON for immediate rectification. d. Audits shall be brought to QA meeting. V. Title Responsible a. Director of Nursing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to complete annual CNA performance evaluation. The facility did not ensure that a CNA had a performance review at least once every 12 months. Review of the personnel file showed the CNA had a hire date in 2016 and no annual evaluation since the last one on file, and HR confirmed the evaluation was overdue and should have been done annually.
Missing Annual GNA Evaluations and Training Documentation: The facility failed to maintain records showing annual performance evaluations and required 12-hour clinical competency training for 3 of 6 GNAs reviewed. HR files for 3 GNAs lacked annual evaluation documentation, and the same 3 GNAs also lacked current annual clinical education records, including one GNA whose last documented training was over a year earlier. The administrator was informed of the missing documentation, and stated the staff educator/ADON had only been in the role for two months while the HR director was out of the office.
Missing Annual CNA Performance Evaluations: The facility failed to ensure two of five CNAs had annual performance evaluations. The DSD reviewed the employee files and confirmed the evaluations were not completed, despite the facility P&P requiring evaluations at the end of the 90-day probationary period and at least annually thereafter. The DSD and DON stated the evaluations were used to assess staff knowledge and skills for resident care.
Failure to complete CNA annual performance reviews and related in-service education. Surveyors found that four of six CNAs reviewed lacked required annual performance reviews or documentation of education tied to review findings. Two CNAs had no annual review since hire, and two others had fair evaluation ratings without comments or evidence of follow-up in-service. The DON and Administrator stated annual reviews and education were expected, but the facility had no policy addressing CNA annual performance reviews.
Missing Annual Staff Performance Evaluations: The facility failed to ensure annual performance evaluations were completed for four sampled employees, including CNAs and an LVN. Personnel records showed no documented annual evaluations for 2024 and 2025. The DHR and DON stated they were aware of the importance of annual evaluations, but there was no established system from prior leadership to ensure they were completed, despite the facility policy calling for annual review of employee performance.
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.
Failure to Complete Annual CNA Performance Evaluation
Penalty
Summary
The facility failed to ensure a performance review was completed at least once every 12 months for 1 of 2 CNA personnel files reviewed. Review of the CNA's personnel file showed a hire date of 09/16/2016 and did not reveal an annual performance evaluation completed since 09/01/2024. During an interview on 06/30/2026 at 4:10 p.m., HR confirmed the CNA had not had an annual performance evaluation since 09/01/2024 and stated that the evaluation should have been completed annually.
Missing Annual GNA Evaluations and Clinical Training Documentation
Penalty
Summary
The facility failed to provide documentation that yearly clinical performance evaluations for Geriatric Nursing Assistants (GNAs) occurred at least every 12 months for 3 of 6 GNA personnel records reviewed. During review of the human resources files on 06/17/2026, the surveyor found that GNA #8, hired 10/04/2021, had no documentation of annual performance evaluations since the date of hire. GNA #21, hired 01/27/1981, also had no annual performance evaluation documentation since the date of hire. GNA #22, hired 04/18/2025, had no annual performance evaluation documentation in the personnel file. The facility also failed to provide documentation of the annual mandatory 12-hour clinical education training for the same 3 GNAs. GNA #8’s last documented 12-hour annual clinical competency training was 04/09/2025. GNA #21 did not have the last 12-hour training present in the personnel file for 2025 and 2026. GNA #22 did not have documentation of a 12-hour annual clinical competency nursing aide training for 2026. At 2:08 PM on 06/17/2026, the administrator was informed of the missing annual performance evaluations and missing annual clinical education training documentation, and stated the current staff educator, who is also the ADON, had only been in the position for two months, while the HR director remained out of the office.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that two of five CNAs had annual performance evaluations. During a concurrent interview and record review on 6/11/2026 at 9:12 a.m. with the DSD, CNA 9 and CNA 10's employee files were reviewed, and the DSD stated that both CNAs did not have annual performance evaluations. The facility's P&P titled Performance Evaluations, dated 2001, stated that a performance evaluation will be completed on each employee at the conclusion of the 90-day probationary period and at least annually thereafter. During interviews on 6/12/2026, the DSD stated that annual performance evaluations were important to ensure staff were evaluated on their knowledge and skills to care for the facility's resident population, and that without them the facility would be unable to determine whether staff were competent and had the knowledge regarding resident care. The DON also stated that annual performance evaluations were needed to assess staff knowledge and skills and to re-educate staff regarding the skills needed to care for the facility's resident population, and that failure to conduct them could result in staff providing lesser quality of care.
Failure to Complete CNA Annual Performance Reviews and Related In-Service Education
Penalty
Summary
The facility failed to complete a performance review for each nurse aide at least once every 12 months and failed to provide regular in-service education based on the outcome of those reviews. Surveyors identified six CNAs employed by the facility for more than a year, and four of the six reviewed did not have the required annual performance review or documentation of in-service education based on the review findings. The facility census was 83. Record review showed CNA AA, hired on 04/08/25, had no documentation of an annual performance review since hire. CNA BB, hired on 05/07/25, also had no documentation of an annual performance review since hire. CNA Z, hired on 03/11/25, had an employer evaluation dated 03/11/26 showing fair ratings for work quality and dependability, but there were no additional comments explaining the ratings and no documentation of additional in-servicing. CNA CC, hired on 10/28/24, had an employer evaluation dated 10/28/25 showing a fair rating for dependability, with no additional comments and no documentation that staff educated the CNA based on the review outcome. The Administrator stated the facility did not have a policy to address nurse aide annual performance reviews, and the DON stated staff were to complete annual performance reviews and provide education on areas of deficiency.
Missing Annual Staff Performance Evaluations
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed for four sampled employees: CNA 1, CNA 2, CNA 3, and LVN 2. During a concurrent interview and record review with the Director of Human Resources, personnel files showed that all four employees lacked documented annual performance evaluations for calendar years 2024 and 2025. The employees reviewed included CNA 1, hired 8/21/2017; CNA 2, hired 12/4/1997; CNA 3, hired in 7/2023 and rehired 05/01/2025; and LVN 2, hired 4/20/2024. The Director of Human Resources stated she had been in her position for approximately two months and had recently realized the importance of ensuring employee performance evaluations were completed annually. The DON stated she began her position at the end of 2025 and had been working on staff training, in-services, and competency assessments, but there was no established system left in place from prior leadership to ensure annual performance evaluations were completed. The facility's policy and procedure for Performance Evaluation stated the facility endeavors to review each employee performance on an annual basis and that evaluations are intended to make employees aware of their progress, areas for improvement, and objectives or goals for future work performance.
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.
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