Missing Annual Performance Evaluations for Unlicensed Staff
Summary
The facility failed to ensure annual performance reviews or evaluations were completed for three of three sampled unlicensed staff employee files, identified in the report as Unlicensed Staff A, Unlicensed Staff B, and Unlicensed Staff C. During interviews and record review, the Director of Staff Development stated that the facility did not do performance reviews and instead presented Annual Clinical Care Training Checklists for some staff. For Unlicensed Staff A, the checklist dated 7/21/25 was reviewed, but it was not identified as a performance evaluation and did not show how skills were assessed, such as by return demonstration or verbal explanation. The Director of Staff Development also stated the form would not capture situations such as an allegation involving a resident where additional training might have been helpful. For Unlicensed Staff B, the Director of Staff Development stated that no performance evaluation had been completed for 2025 or 2026 and acknowledged that all unlicensed staff were supposed to be completed by April 1, 2026, but none had been done yet. For Unlicensed Staff C, the Director of Staff Development stated the staff member had been hired in January 2025 and no performance evaluation had been completed by January 2026. The Administrator confirmed that the Director of Staff Development was responsible for annual performance evaluations for unlicensed staff and stated the Annual Clinical Care Training Checklist was not the approved performance evaluation form. The facility handbook stated that annual, documented reviews were established as a standard to formalize an interactive conversation about performance, goals, and objectives, and the approved Performance Evaluation form was also reviewed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Annual Performance Evaluations for Nursing Staff: The facility failed to complete annual performance evaluations for four of five nursing staff records. Facility policy required timely annual evaluations after 90 days, but review of personnel files showed that four NAs did not have evaluations completed based on their hire dates. HR staff confirmed the facility was behind in evaluations and had not completed them for those employees.
Failure to Complete Annual CNA Performance Evaluations: The facility did not complete annual performance evaluations for two CNAs. A file review showed no annual evals for CNA 3 and CNA 4 for the review period, and the DSD confirmed both were missing. The ADM stated annual evaluations are important for identifying staff issues and additional training needs, and the facility policy requires each employee to receive an annual performance evaluation review.
The facility failed to complete a required annual CNA performance review for one CNA, Employee #8, whose personnel record had no documented evaluation. The HR Director stated CNA evaluations were done each year on Oct. 1 to review the prior year and confirmed this CNA was not reviewed 12 months after starting at the facility. The Facility Assessment stated weaknesses identified in CNA performance reviews and annual competency assessments would be addressed through in-service training.
Missing CNA Annual Performance Evaluation: The facility failed to complete and maintain the annual performance evaluation for one CNA. The CNA's file had no current evaluation, and the DSD and DON stated the review should have been done annually, including when the CNA returned from leave and light duty. The employee handbook stated staff generally receive performance evaluations and that work during the year is evaluated by the supervisor.
The facility failed to complete annual performance evaluations for three NA personnel records as required by policy. Review of the files for three NAs showed no evaluations completed at least every 12 months, and the NHA stated the issue was discovered after prior HR staff were not completing staff education correctly.
Surveyors determined that the facility did not complete required annual performance evaluations or provide the mandated 12 hours of annual in‑service education for multiple nurse aides. During interviews, the HR Director acknowledged that annual performance reviews had not been done, and the Nursing Home Administrator confirmed that the affected nurse aides had not received the required in‑service hours within 12 months of their hire date anniversaries.
Missing Annual Performance Evaluations for Nursing Staff
Penalty
Summary
The facility failed to complete annual performance evaluations for four of five nursing staff personnel records, identified as Nurse Aides E10, E11, E12, and E13. Facility policy titled Employee Performance Evaluations, dated 3/16/26, stated that all employees receive timely, fair, and consistent performance evaluations, with evaluations conducted annually after 90 days. Review of personnel records showed that E10 was hired on 2/7/24 and had a last performance evaluation dated 6/20/24; E11 was hired on 10/30/23 and had a last evaluation dated 11/11/24; E12 was hired on 2/29/24 and had a last evaluation dated 8/7/24; and E13 was hired on 6/22/23 and had a last evaluation dated 6/24/24. The records did not include annual performance evaluations based on each employee’s date of hire. During interview, Human Resource Employee E4 stated the facility was behind in evaluations and trying to get caught up, and confirmed that annual performance evaluations had not been completed for these four nursing staff records.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed for two Certified Nursing Assistants, CNA 3 and CNA 4. During a review of five employee files, the annual evaluation audit did not show a completed 2025-2026 evaluation for CNA 3, whose date of hire was 6/29/2015, or for CNA 4, whose date of hire was 3/15/2023. In an interview, the Director of Staff Development stated both CNAs did not have annual evaluations completed for the year 2025-2026 and stated annual evaluations should have been completed to ensure staff were compliant with facility policies and expectations. The Administrator stated annual evaluations were important because they gave management the opportunity to address issues staff needed to improve on or issues requiring additional training. The facility policy titled Annual Performance Evaluation dated 7/2019 stated that annually, each employee will receive a performance evaluation review.
Missing Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure a nurse aide performance review was completed at least once every 12 months and that areas of weakness were identified and addressed for 1 of 2 sampled CNAs, Employee #8. Employee #8 was hired as a CNA on 10/21/2024, and the personnel record lacked documented evidence of a nurse aide performance evaluation. During interview on 04/22/2026, the HR Director stated CNA performance evaluations were completed every year on October 1st to review the prior year and explained that, because of the date of hire, Employee #8 was not reviewed for performance. The HR Director confirmed Employee #8's nurse aide performance review was not completed 12 months after starting at the facility. The Facility Assessment, updated 03/2026, documented that areas of weakness identified in nurse aide performance reviews and annual competency assessments would be addressed through in-service training.
Missing CNA Annual Performance Evaluation
Penalty
Summary
The facility failed to conduct the CNA annual performance evaluation for one of three sampled employees, CNA M. Review of the employee file showed CNA M was hired on 7/9/2013, but there was no current annual performance evaluation in the file. The report stated this evaluation was a formal, documented review of the employee's work over the past year, assessing performance against established goals and expectations. During interviews, the DSD stated the business office records showed CNA M's last annual performance evaluation was on 8/27/2023, but the hard copy could not be found and the date was known only because CNA M received a raise that day. The DON stated the evaluation should have been done annually and was not sure why it was missed. In a follow-up interview, the DSD stated CNA M went on leave in 6/2025 and returned on light duty on 1/18/2026, and confirmed the performance evaluation should have been completed when she came back to work. The employee handbook stated staff members generally receive a performance evaluation at the same time, generally in December, and that work during the year will be evaluated by the supervisor.
Failure to Complete Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations at least once every 12 months for three nurse aide personnel records: NA Employee E8, NA Employee E9, and NA Employee E10. Facility policy titled In-Service Training, Nurse Aide, dated 2/11/26, stated that the facility completes a performance review of nurse aides at least every 12 months. Review of the personnel files for NA Employee E8, hired 12/8/20, NA Employee E9, hired 6/5/05, and NA Employee E10, hired 2/21/24, showed that their records did not include annual performance evaluations as required. During interview, the NHA stated that performance evaluations were not being completed because the previous HR person was not completing staff education correctly, and that evaluations were done for everyone in March. The NHA confirmed that the facility failed to complete annual performance evaluations at least once every 12 months for these three nurse aide personnel records.
Failure to Complete Annual Nurse Aide Performance Reviews and In‑Service Education
Penalty
Summary
The facility failed to complete required annual performance reviews and provide mandated annual in‑service education for nurse aides. Surveyors reviewed facility documents and interviewed the Human Resources Director, who confirmed that annual performance evaluations had not been completed for five of five nurse aides (Employees E2, E3, E4, E5, and E6). In a separate interview, the Nursing Home Administrator confirmed that these same nurse aides had not received the required 12 hours of annual in‑service education within 12 months of their hire date anniversary, as required by federal and state regulations. No residents or specific patient conditions were mentioned in the report, and the deficiency focused solely on the facility’s failure to conduct timely performance reviews and provide the corresponding in‑service education for the identified nurse aides.
Plan Of Correction
Employees E2, E3, E4, E5, and E6 from facility documents given to the survey team will have their annual performance evaluation completed by their Department Manager/DON. The DON/Designee will complete annual evaluations for Nurse Aide on an annual basis. The Administrator will provide education to the facility DON/Designee on the importance of completing Annual Evaluations on the employee in the facility. These evaluations will include Core Values and Objectives, of Quality of Work, Attendance and Punctuality, Communication Skills, Judgement and Decision-making skills Cooperation and Teamwork and Knowledge of position. Audits will be completed by the HR Director/Designee on 10% of Nurse Aide employees each month that the Employee Annual Evaluation has been completed. The results of these audits will be reviewed by the QAPI committee for further recommendations
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