Failure to Complete Annual CNA Evaluations and Full Background Screening
Penalty
Summary
Surveyors identified that the facility did not ensure required annual performance evaluations were completed and properly documented for two of four CNAs reviewed, and did not complete a full pre-employment background check for one CNA. Personnel file review showed CNA 2, hired on 9/28/23, had a performance evaluation dated 9/28/24 but no evaluation for 2025, and the existing evaluation lacked supervisor comments regarding new goals, objectives, and commitments. CNA 4’s performance evaluation was dated 7/20/25, although the CNA’s hire date of 6/1/19 indicated the annual evaluation was due on 6/1/25, and this evaluation also lacked supervisor comments on new goals, objectives, and commitments. During interview, the DSD confirmed there was no 2025 performance evaluation for CNA 2 and stated that performance evaluations should be completed annually and that annual reviews of CNA skills are important to ensure safe resident care. Record review further showed that CNA 4’s personnel file did not contain a full background check as required by facility policy. The file only included a 7-year criminal court record search for Los Angeles County and lacked documentation of an abuse registry check and an exclusion list database check, including the OIG LEIE. Facility policies titled “Background Screening Investigations,” “Hiring,” “Staff Development Program,” and “Performance Evaluations” indicated that background and criminal checks must be initiated within two days of an employment offer and completed prior to employment, including checks of the state nurse aide registry and applicable licensing boards, and that each employee’s job performance must be reviewed at least annually. The policies also stated that CNAs must complete at least 12 hours of annual in-service training to ensure continuing competency and address weaknesses identified in performance evaluations and the facility assessment.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.