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F0730
F

Failure to Complete Annual CNA Evaluations and Required In-Service Education

Mount Horeb, Wisconsin Survey Completed on 07-09-2025

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 annual performance evaluations for all nurse aides and did not provide the required 12 hours of annual in-service education for several staff members. Record review showed that none of the five nurse aides selected for evaluation had performance reviews completed every 12 months as required by facility policy. Additionally, four out of five nurse aides did not complete the mandated 12 hours of continuing education within the year, with documented hours ranging from 8.5 to 10 out of the required 12. The facility also lacked a specific policy or procedure addressing the required in-service education for nurse aides. Interviews with the Nursing Home Administrator confirmed that the required annual evaluations and education hours were not completed for the staff in question. The administrator acknowledged that each CNA should have a current evaluation and at least 12 hours of annual education, but records did not support compliance with these requirements. The deficiency was identified through both record review and staff interviews, with specific examples cited for each staff member involved.

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