Health inspection·June 4, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00896421. Representing the Department, HFEN # 43452. A Class B Citation was written. 42 CFR §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. 22 CCR § 72521 Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 4/24/2024, an unannounced visit was conducted at the facility to investigate compliant regarding resident's neglect, care, and treatment. The facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily and was placed in a visible and prominent place as indicated in the facility's policy and procedure (P&P) on Posting Direct Care Daily Staffing Numbers. As a result, the total number of staff and the actual hours worked by the staff on 4/27/2024 to 4/29/2024 were not readily accessible to residents and visitors. During an observation on 4/27/2024 at 1:16 p.m., there was no Nurse Staffing Information posted in the facility. During an observation on 4/28/2024 at 10:25 a.m., there was no Nurse Staffing Information posted in the facility. During an observation on 4/29/2024 at 11:10 a.m., there was no Nurse Staffing Information posted in the facility. On 4/29/2024 at 3:35 p.m., during an interview, the Director of Staff Development (DSD) stated that it is her responsibility to post the Nursing Staffing Information which should be readily available in the Receptionist Area and in the Nursing Station. DSD stated, she was not able to do the Nursing Posting on 4/27/2024 to 4/29/2024. DSD reviewed facility's P&P on Posting Direct Care Daily Staffing Numbers with the surveyors and stated, she will post the DHPPD appropriately. During an observation on 4/30/2024 at 11:18 a.m., a projected, not an actual Direct Care Services Hours Per Patient Day (DHPPD) was observed posted at the receptionist area and on the counter of Nursing Station 1. During a follow-up interview with DSD on 4/30/2024 at 3:45 p.m., DSD stated, only the projection hours are to be posted in the Nurse Posting, not the actual hours. During an observation on 5/1/2024 at 1:15 p.m., a projected, not an actual DHPPD was observed posted at the receptionist area and on the counter of Nursing Station 1. A review of the facility's P&P titled, "Posting Direct Care Daily Staffing Numbers" reviewed on 1/25/2024, indicated the facility would post on a daily basis for each shift the nurse staffing daily, including the number of nursing personnel responsible for providing direct care to residents ... the information recorded on the form shall include the following: the actual time worked during that shift for each category and type of nursing staff. The facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily and was placed in a visible and prominent place as indicated in the facility's P&P on Posting Direct Care Daily Staffing Number. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors. The above violations had a direct relationship to the health, safety, or security of all the residents in the facility.