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.
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.
Failure to Complete Annual CNA Performance Evaluation: The facility failed to ensure that one CNA received the required annual performance review per policy. The DSD stated the CNA’s annual evaluation was overdue, and the DON stated evaluations are used to review staff performance, identify strengths and weaknesses, and determine if additional training is needed. The facility policy required formal written evaluations annually after the initial 90-day review.
Missing Annual Performance Evaluations for Nurse Aides: The facility failed to complete required APRs for multiple nurse aides, including a CNA and an RNA. Record review and interviews with the DSD and DON showed that annual evaluations were not completed as required by facility policy, which calls for a review after the 90-day probationary period and at least annually thereafter.
The facility failed to complete annual PE for five sampled CNAs. Record review with the DSD showed one CNA had a last PE in 2024 with no later evaluation, two CNAs hired in 2024 had no PE in their files, and two other CNAs hired in 2022 had no annual PE after their most recent evaluations. The facility policy stated employee job performance shall be reviewed and evaluated at least annually.
Surveyors found that two CNAs did not have timely, fully documented annual performance evaluations, and one CNA lacked a complete pre-employment background check. One CNA had no evaluation for the most recent year, and another’s evaluation was completed late; both evaluations lacked supervisor comments on new goals, objectives, and commitments. The same CNA’s file contained only a limited county criminal search without required abuse registry and OIG LEIE exclusion checks, despite facility policies requiring comprehensive background screening and annual performance reviews to support ongoing CNA competency.
Missing Annual CNA Performance Review: The facility failed to ensure one CNA had an annual performance review in the personnel file. During record review, the CNA’s file showed hire on 2/4/25 but no documented annual evaluation. The DSD stated he was not sure how annual reviews were tracked and confirmed there should have been a review in the file. The facility handbook and P&P both required annual documented performance evaluations.
Surveyors identified that an annual performance evaluation was not completed for one of five sampled CNAs, contrary to facility policy requiring at least yearly reviews of each employee’s job performance. Review of the CNA’s personnel file with the DSD showed the last evaluation was documented more than a year prior, and the DSD acknowledged that no subsequent evaluation had been done. The facility’s policy also required that completed evaluations be forwarded to HR for inclusion in the personnel record, but no current evaluation was present, creating the potential for the CNA to provide care that may not meet residents’ needs.
Missing Annual CNA Performance Evaluations: The facility did not complete required performance evaluations for two CNAs, as their personnel files contained no annual evaluations since hire. The DSD acknowledged the evaluations were not completed, and the DON stated evaluations are used to determine whether staff are performing the job correctly and should occur after hire and annually thereafter.
Missing Annual Performance Evaluations for Unlicensed Staff: The facility failed to complete annual performance evaluations for three sampled unlicensed staff members. The DSD stated the facility used Annual Clinical Care Training Checklists for some staff, but these were not the approved performance evaluation form and did not document a true performance review or capture opportunities for additional training. The ADM confirmed the DSD was responsible for the evaluations and that the approved form had not been completed for the sampled staff.
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