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F0947
D

Failure to Complete Annual Performance Reviews and Provide Regular In-Service Education for Nurse Aides

Big Rapids, Michigan Survey Completed on 07-18-2025

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 complete a performance review of every nurse aide at least once every 12 months and did not provide regular in-service education based on the outcomes of these reviews. Review of the facility's assessment indicated that while there was an orientation process and ongoing training plan in place, actual implementation was lacking. Specifically, review of employee files showed that one CNA, hired in December 2023, had no performance evaluations completed since hire, and only minimal education was documented, with a significant gap in ongoing training. Another CNA, hired in October 2022, also had no performance evaluations completed for 2023 or 2024. During an interview, the Nursing Home Administrator confirmed that performance evaluations had not been conducted in 2024 due to a hold placed by the HR department to streamline the process, and was unsure if evaluations had been completed in 2023. The administrator stated that yearly education was provided through a computerized training program, bi-monthly meetings, and a yearly skills assessment/in-service, but documentation reviewed did not support that regular in-service education or performance reviews were consistently completed as required.

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