Deficiencies in Staff Evaluation, Policy Accessibility, and Pest Control
Penalty
Summary
Facility administration failed to establish and ensure systems for evaluating staff performance and providing required education based on performance reviews and facility assessment. Review of an employee file for a GNA revealed only one annual performance evaluation over seven years of employment, and insufficient annual training on cognitive impairment and mental illness. Interviews with the DON and HR Director confirmed that annual performance evaluations were not conducted for nursing staff, and there was no formal process for ongoing competency verification or structured training needs assessment. Staff interviews indicated that policies and procedures were not readily available or accessible to all staff. Multiple staff members believed that policy binders were located in the nurse's station, but upon inspection, only a wound care policy binder was found. Other staff referenced policies being kept in various locations or with department heads, but the DON confirmed that direct care staff did not have access to policies and procedures on the units, and only one nursing manual was available in the facility. The facility also lacked an effective pest control program. Complaints and observations revealed ongoing issues with mice and cockroaches, unsanitary kitchen conditions, and structural deficiencies such as gaps and holes allowing pest entry. Pest control company recommendations for maintaining sanitation and building repairs were not implemented, and documentation showed only monthly pest control visits despite claims of increased frequency. Maintenance staff were not receiving pest control reports, and structural recommendations were not followed up, contributing to persistent pest issues.