Failure to Conduct Annual Performance Evaluations for Nurse Aides
Summary
The facility failed to conduct annual performance evaluations for its nursing staff, specifically for five nurse aides identified as Employees E11, E12, E13, E14, and E15. This deficiency was discovered through a review of personnel records and confirmed during an interview with the Nursing Home Administrator. The evaluations were not completed based on the date of hire, as required by the regulations, which stipulate that a performance review must be conducted at least once every 12 months for each nurse aide. This oversight indicates a lapse in adhering to the mandated staff development protocols.
Plan Of Correction
As a newly established company, we acknowledge this deficiency and view it as an opportunity to build a comprehensive and sustainable performance management system from the ground up. Recognizing the importance of staff development and regulatory compliance, we are committed to thoroughly evaluating all existing personnel and creating a robust framework for performance evaluations that supports both accountability and professional growth. To allow for a thoughtful and fair assessment of our current workforce, we have established a corrective action date of June 17, 2025. This extended timeline provides the necessary window to evaluate all nursing personnel, review existing training and evaluation protocols, and implement a standardized annual review system that aligns with each employee's hire date. During this period, Human Resources will work closely with the Director of Nursing and department heads to build a tracking system that ensures timely evaluations moving forward. A performance evaluation template based on job-specific competencies and core values will be finalized and implemented by the corrective date. All nurse aide personnel files will be audited and updated, and a schedule will be created to complete all outstanding evaluations by June 17. Training for supervisors on conducting effective and compliant evaluations will also be completed prior to that date. Addendum to Ensure Compliance with 60-Day Requirement: The facility is committed to completing all outstanding performance evaluations for current nurse aide personnel by the regulatory deadline of June 17, 2025. Human Resources, in collaboration with the Director of Nursing, has begun auditing personnel files and will implement a tracking system by May 31 to support timely completion. A standardized evaluation template will be finalized, and supervisors will receive in-service training to ensure evaluations are conducted appropriately. While every effort will be made to meet the June 17 target, if additional time is needed to ensure thorough and meaningful evaluations, the facility will continue working diligently to complete all evaluations as soon as possible. A long-term evaluation schedule based on hire dates will be implemented beginning July 1, 2025, to support ongoing compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to complete annual performance evaluations for three nurse aides. Personnel record review showed each aide was hired on 7/1/23, and none of the three files contained the required yearly performance evaluation. The NHA confirmed the missing evaluations during interview.
The facility failed to complete annual performance reviews for three nurse aides reviewed. Record review showed the aides did not have current annual performance reviews in their personnel files, and the NHA confirmed the omission during interview.
A CNA involved in an abuse allegation did not have an annual PE on file, even though the facility's handbook said employees may be reviewed about once per year and the PE should be based on job performance and duties. The CNA was hired in 2024, but the DSD and VPHR could not locate the required evaluation during record review. The case involved a resident with HTN, anxiety, and adult failure to thrive who had severely impaired cognition and no decision-making capacity; an SBAR and IDT note documented an allegation that the CNA tapped the resident on the lips and acted aggressively during care, which the CNA denied.
Missed Annual CNA Performance Reviews: The facility failed to complete required annual performance reviews for 5 CNAs. HR stated reviews were delayed while the union worked on new wage rates and that prior reviews could not be located. The DON stated annual reviews were expected and many were overdue.
A facility failed to complete an annual performance evaluation for a CNA whose file showed the last evaluation was in 2012. The CNA was linked to a resident complaint of being smacked on the hand and a family member’s complaint about the CNA’s care. One resident had hemiplegia, hemiparesis, osteoarthritis, and depression and needed extensive ADL assistance, while another resident had dementia, hepatic failure, spinal stenosis, and severe cognitive impairment with dependence for all ADLs.
Missing Annual CNA Performance Reviews: The facility did not complete yearly performance reviews for 5 of 5 CNAs reviewed. Record review showed each CNA lacked a performance evaluation within the past 12 months, and the NHA acknowledged that the annual reviews were not completed.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations at least once every 12 months for three of three nurse aide personnel records, including NA Employee E23, NA Employee E24, and NA Employee E25. Review of each personnel file showed a date of hire of 7/1/23, and each record lacked an annual performance evaluation at least every 12 months as required. During an interview on 8/4/26 at 1:55 p.m., the Nursing Home Administrator confirmed that the facility failed to complete the required annual performance evaluations for all three nurse aides.
Missing Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews at least once every 12 months for three of three nurse aides reviewed: Employee E13, Employee E14, and Employee E15. Review of facility documentation and employee personnel files showed that these nurse aides did not have completed, up-to-date annual performance reviews. During an interview on July 30, 2026, at 2:30 p.m., the Nursing Home Administrator, Employee E1, confirmed that the facility had failed to complete annual performance reviews for Employees E13, E14, and E15. The cited regulatory references were 28 Pa. Code 201.14(a) and 28 Pa. Code 201.19(2).
Missing Annual Performance Evaluation for CNA Involved in Abuse Allegation
Penalty
Summary
The facility failed to ensure that one sampled CNA involved in an allegation of staff-to-resident abuse received a performance evaluation at least once every 12 months, as required by the facility's Employee Handbook. The deficiency involved CNA 1, who was hired on 8/27/2024 and whose annual performance evaluation should have been completed in 8/2025, but could not be found in the employee personnel file, HR records, or by the DSD and VPHR during the survey review. Resident 1 was admitted to the facility with diagnoses including HTN, anxiety disorder, and adult failure to thrive. The resident's MDS dated 6/11/2026 indicated severely impaired cognitive skills for daily decision making and the need for substantial/maximal assistance with ADLs. A later H&P dated 7/19/2026 stated the resident did not have decision-making capacity. On 7/22/2026, an SBAR documented an allegation that a student reportedly saw CNA 1 tap Resident 1 on the lips after the resident used profanity during care, and that CNA 1 acted aggressively toward the resident. The IDT conference dated 7/23/2026 documented an allegation of physical abuse and noted the resident had no injuries or signs of distress. During interview, CNA 1 denied touching or tapping the resident's mouth, denied being rough or aggressive, and denied grabbing the resident by the neck during transfer. The DSD, VPHR, and DON all confirmed that no performance evaluation for CNA 1 could be located and stated that annual evaluations were expected based on the employee's hire date and were intended to review performance and areas for improvement.
Missed Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for 5 of 5 CNAs identified in the report: Staff M, Staff N, Staff O, Staff P, and Staff Q. The facility’s staff list showed that Staff M, Staff N, Staff O, Staff P, and Staff Q had been hired 22 months, 16 months, 63 months, 23 months, and 23 months before survey, respectively. No documentation was provided to show performance reviews were completed for Staff M, Staff N, Staff O, or Staff P. Staff Q had one Employee Performance Review dated 11/27/2025, which was 15 months after hire, and no other performance review documentation was provided. During interview, Human Resources stated the facility was waiting to complete annual performance reviews because the employee union was still working on new wage rates, and that performance reviews were required every 12 months but had not been done because employees wanted to know how the reviews would affect their wages. The Human Resources staff also stated they could not locate prior performance reviews for the listed staff. The DON stated that annual performance reviews were expected and that many were overdue.
Missing Annual Performance Evaluation for CNA with Resident Complaints
Penalty
Summary
The facility failed to complete an annual performance evaluation for CNA 6, whose personnel file showed the last documented performance evaluation was in 2012. The facility’s policy titled Performance Evaluations, revised 2/2026, stated that the job performance of every employee was to be reviewed and evaluated at least annually. During interview, the Interim DON confirmed the missing evaluation and stated that performance evaluations were important to identify what staff were lacking and what areas of improvement needed to be addressed. The deficiency involved CNA 6 while there were resident complaints and allegations involving that aide. Resident 8’s record showed a readmission with diagnoses including hemiplegia, hemiparesis following cerebral infarct, osteoarthritis, and depression, and the MDS indicated the resident could make herself understood and understand but needed supervision with eating and was dependent on staff for oral hygiene, toileting hygiene, dressing, showering, and personal hygiene. Resident 8 reported in an SBAR form that CNA 6 smacked her on the right hand, and later stated the aide smacked her and pointed to her right wrist. In addition, Resident 11’s family member stated they did not want CNA 6 to care for Resident 11 and was unsatisfied with CNA 6’s work; Resident 11’s record showed diagnoses including hepatic failure, lumbar spinal stenosis, dementia, and cataract, and the MDS indicated severely impaired cognition and dependence for all ADLs.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility did not complete performance reviews for CNAs at least every 12 months for 5 of 5 CNAs reviewed: CNA3, CNA4, CNA5, CNA6, and CNA7. The facility’s policy, Job Descriptions and Performance Evaluations, dated 9/20, states that performance evaluations measure standards against job performance and are intended to aid management in analyzing and improving the facility’s services and structure and to improve the quality of work performance. Record review showed CNA3, hired 2/16/25, did not have a yearly performance review completed in the last 12 months; CNA4, hired 9/21/09, did not have a yearly performance review completed in the last 12 months; CNA5, hired 5/23/25, did not have a yearly performance review completed in the last 12 months; CNA6, hired 1/13/20, did not have a yearly performance review completed in the last 12 months; and CNA7, hired 12/31/97, did not have a yearly performance review completed in the last 12 months. On 7/27/26 at 12:40 PM, the NHA stated the facility did not have yearly performance reviews for the CNAs and acknowledged that the reviews should have been completed.
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