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F0730
F

Failure to Conduct Annual Performance Reviews for Nurse Aides

Lancaster, Pennsylvania Survey Completed on 04-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct annual performance reviews for five nurse aides, identified as Employees E5, E6, E7, E8, and E9, as required by regulation §483.35(d)(7). This deficiency was identified through a review of staffing records and performance reviews, which revealed that these staff members did not have their performance reviews completed within the last year. The Nursing Home Administrator confirmed during an interview that the performance reviews for these staff members were not conducted.

Plan Of Correction

1. Facility completed performance reviews on Employee 5, Employee 6, Employee 7, Employee 8, and Employee 9. 2. All employees reviewed and those needing a performance review will be completed. 3. NHA and HR to educate department leaders on completing annual reviews for respective staff and departments. 4. NHA, HR, or designee, will perform random audits to ensure employee reviews are done annually around their hiring anniversary date weekly for 2 weeks, then monthly for 2 months. Results of audits will be submitted to monthly QAPI for review and recommendations.

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