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F0730
F

Failure to Complete Annual CNA Performance Reviews

Three Rivers, Michigan Survey Completed on 10-30-2025

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 reviews for three Certified Nursing Assistants (CNAs) who had been employed for more than 12 months. Personnel file reviews for these CNAs showed no evidence of annual performance evaluations within the past year. This was confirmed by both the Business Office Manager (BOM) and the Nursing Home Administrator (NHA), who acknowledged that the required evaluations had not been conducted or documented as per facility policy. Interviews with facility staff further confirmed the absence of these reviews, with the BOM stating that performance evaluations are expected annually and should be maintained in employee files. The facility's policy specifies that additional training should be provided based on areas of weakness identified in performance reviews, and that such education should be completed within 90 days of the appraisal. The lack of completed performance reviews resulted in the potential for unidentified performance concerns and unmet training needs for the CNAs involved.

See complete original report
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