Health inspection·October 25, 2023

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the minimum requirement to provide 3.5 Direct Care Service Hours Per Patient Day (DHPPD, it is the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census) for eight days for the month of August to meet the resident's needs for one of two residents (Residents 1). This failure had the potential to affect Resident 1 and other residents ' care and wellbeing. Findings: 1. A review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including type 2 diabetes (DM, high blood sugar), hemiplegia and hemiparesis (one-sided weakness and paralysis), and depression (a mood disorder that interferes with daily life). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/02/23, the MDS indicated he had a brief interview of mental status (BIMS, a structured cognitive test) score of 15 (cognitively intact). During a review of the facility's shower schedule, the schedule indicated that his shower days were Mondays and Thursdays. During a review of Resident 1's care plan for ADL, the care plan indicated Resident 1 requires extensive to total assistance by one staff with bathing/showering 2X/week and, as necessary, was initiated on 8/25/23. During a review of Resident 1's Activities of Daily Living (ADL) task for bathing, the task indicated that he took a shower on 8/24/23 (Thursday) and 8/31/23 (Thursday), but not 8/28/23 (Monday). During a document review titled Census and Nursing Hours Per Patient Day in August 2023, it was indicated that the following dates with actual DHPPD were below 3.5: 8/05-3.27; 8/06-3/16; 8/12-3.49; 8/19-3.49; 8/20-3.47; 8/26-3.25; 8/27-2.99; and 8/28-3.37. During an interview and DHPPD review on 9/01/23 at 11:30 a.m. with the Executive Leader (EL), she confirmed the above record review. During an interview and facility document review on 9/01/23 at 11:40 a.m. with the Administrative Assistant (AA), she stated they were understaffed in August. The AA acknowledged that the Direct Care Service Hours Per Patient Day (DHPPD) should have been at least 3.5. Page 1 of 2 055462 055462 10/25/2023 Hazel Hawkins Memorial Hospital D/P Snf 911 Sunset Drive Hollister, CA 95023

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview and observation on 9/01/23 at 1:10 p.m. with Resident 1 in his room, he was sitting in bed and stated that he was not able to take a shower for five days because there were not enough Certified Nurse Assistants (CNAs). Resident 1 further stated that he was able to take a shower on 8/31/23 after he made a complaint to a nurse. During an interview and record review on 9/01/23 at 2:10 p.m. with Assistant Director of Nursing A (ADON A), she confirmed that Resident 1 did not take a shower on 8/28/23. ADON A stated that CNAs were understaffed on 8/28/23. During an interview on 9/01/2022 at 2 p.m. with ADON A, she agreed the delivery of care to residents could be affected whenever they have short staffing. During a review of the All Facilities Letter (AFL) 21-11, dated 3/17/21, the AFL indicated, The 3.5 DHPPD staffing requirement, of which 2.4 hours per patient day must be performed by CNAs, is a minimum requirement for SNFs (Skilled Nursing Facilities). SNFs shall employ and schedule additional staff and anticipate individual patient needs for the activities of each shift, to ensure patients receive nursing care based on their needs. The staffing requirement does not ensure that any given patient receives 3.5 or 2.4 DHPPD; it is the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census. 055462 Page 2 of 2