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.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
056394
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056394
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Golden Pavilion Healthcare
99 Escuela Drive
Daly City, CA 94015
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056394
If continuation sheet
Page 2 of 2
