Three certified nursing assistants had worked at the facility for more than 12 months without receiving their mandatory annual performance reviews, according to an inspection report released after the October 30 complaint investigation.
Business Office Manager BB discovered the missing evaluations when inspectors requested the files at 8:12 that morning. She reviewed employee files for the three CNAs and confirmed no performance reviews had been completed in the past 12 months.
"I heard it from the horse's mouth; performance evaluations were not done," the business office manager told inspectors after speaking with Administrator A about the missing reviews.
The administrator acknowledged his awareness of the problem during a 3:16 p.m. interview that same day. He confirmed that performance reviews were necessary to ensure staff have the necessary skills to care for residents.
Federal regulations require nursing homes to observe each nurse aide's job performance and provide regular training. The facility's own policy, updated just two days before the inspection, states that additional training must be provided to nursing assistants based on weaknesses identified in their performance reviews.
Without these evaluations, the facility cannot identify performance concerns or determine what additional training each nursing assistant needs. The policy requires any necessary education based on performance appraisals to be completed within 90 days of the review.
The business office manager emphasized the importance of the missing evaluations. She confirmed that performance reviews were critical to ensure staff had the skills needed to complete their job duties.
Healthcare performance review guidelines cited in the inspection report highlight that such evaluations lead to improved performance, greater productivity, and better overall experience for patients. The missing reviews at The Orchards represent a systemic failure in staff oversight that could affect the quality of care provided to many residents.
The facility's policy acknowledges this connection between staff evaluation and resident care. By failing to conduct the required annual reviews, administrators cannot determine whether their nursing assistants need additional training in specific care areas or identify potential performance issues before they impact residents.
The three nursing assistants continued working without the benefit of formal feedback on their job performance or identification of areas where they might need additional support or training. This gap in supervision occurred despite the facility's written commitment to provide ongoing education based on performance review outcomes.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, but noted it affected many residents. The failure to evaluate nursing assistant performance creates the potential for unidentified performance concerns, lack of training related to staff performance review outcomes, and unmet care needs.
The timing of the violation adds to its significance. The facility updated its nurse aide training policy just two days before the inspection, acknowledging the requirement for performance-based additional training. Yet the three CNAs remained without their mandatory annual evaluations despite having worked at the facility well beyond the 12-month requirement.
Administrator A's admission that he was aware of the missing performance reviews raises questions about management priorities at the facility. Despite knowing the evaluations hadn't been completed, no action had been taken to address the deficiency before inspectors arrived.
The business office manager's role in discovering the missing files during the inspection suggests the oversight failure extended beyond a simple administrative delay. The fact that she had to confirm the absence of reviews after speaking directly with the administrator indicates the problem was known but unresolved at the management level.
Federal regulations exist specifically to ensure nursing home staff receive adequate supervision and training to provide quality care. Performance reviews serve as a critical tool for identifying staff who may need additional support or training to meet resident care standards.
At The Orchards, this oversight mechanism had completely broken down for at least three nursing assistants, leaving gaps in quality assurance that could directly impact the residents who depend on these staff members for daily care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Orchards At Three Rivers from 2025-10-30 including all violations, facility responses, and corrective action plans.