Health inspection·October 3, 2024

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to train and review the performance of three out of three sampled Certified Nursing Assistants (CNAs) when employee files of CNA 1, CNA 2, and CNA 3 lacked documentation of initial training as well as a performance review required by facility policy and procedure. This failure has the potential to result in untrained CNAs providing unsafe care that could cause harm to Residents. Findings: A review of a documented titled New Hire Report dated 10/01/23 to 11/30/23 indicated that CNA 1, CNA 2, and CNA 3 were all hired in October of 2023. It further indicated that CNA 1 ended employment on April 2024; CNA 2 ended employment on March 2024; CNA 3 ended employment on February 2024. During a concurrent interview and record review on 10/02/24 at 10:35 AM with the Director of Staff Development (DSD), CNA 1 ' s employee file was reviewed. The DSD stated that after someone is hired, they will have two days of classroom orientation that includes topics about patient care. The DSD stated that this classroom instruction should be completed prior to staff starting to work on the unit. The DSD further stated that CNA 1 ' s employee file was missing the onboarding documents, and they would need to look for them. During a concurrent interview and record review on 10/02/24 at 2:30 PM with the DSD, CNA 2 and CNA 3 ' s employee files were reviewed. The DSD stated there was not a competency assessment done for CNA 2 or CNA 3. During a concurrent interview and record review on 10/03/24 2:19 PM with the DSD, CNA 1 ' s employee file was reviewed again. The employee file indicated that there was still no documentation of a performance or competency evaluation for CNA 1. When asked if the DSD was able to locate any documentation of a performance evaluation the DSD stated, no it doesn ' t seem like she ' s got one. During a concurrent interview and record review on 10/03/24 at 2:43 PM with the Assistant Director of Nursing (ADON), the facility document titled Certified Nursing Assistant Competency Assessment was reviewed. The document indicated that there were 67 different functions [skills] that a CNA had to demonstrate competency in. The ADON stated that this document should be done by the time you ' re done with orientation. The ADON further stated that CNA should not be independently working with residents until you are done with the competency assessment. Page 1 of 2 056394 056394 10/03/2024 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the ADON on 10/03/24 at 2:58 PM with the ADON, the ADON stated that the competency assessment and performance evaluation are important because, we have to be able to validate that someone is trained. A review of a facility policy and procedure (P&P) titled Performance Evaluations, last revised June 2010, indicated that A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually .The written performance evaluations will contain the director ' s and/or supervisor ' s remarks and suggestions, any action that should be taken (e.g., further training, etc.), and goals .The completed performance evaluation will be sent . to be placed in the employee ' s personal record. During a concurrent interview and record review on 10/03/24 at 3:32 PM with the Director of Nursing (DON), the employee files of CNA 1, CNA 2, and CNA 3 were reviewed. The employee files indicated that there was no initial competency evaluation during orientation or a performance evaluation after 90 days of hire for all three employees. The DON stated that the DSD will coordinate the orientation for CNAs. The DON further stated that the skills assessments are important so that CNAs can do the job properly . we can ' t have them on the floor not knowing how to do things. 056394 Page 2 of 2