Health inspection·August 23, 2024

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. On 7/9/2024 the California Department of Public Health (CDPH) made an unannounced visit to investigate a complaint regarding quality of care. 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 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 in the facility was not readily accessible to residents and visitors. During an observation on 7/10/2024 at 9:30 a.m., observed in Nursing Station 1 (NS 1), a facility document (untitled) initially dated 6/8/2024 then was crossed with a line and was changed to 7/4/2024. The same facility document (untitled) with a now date of 7/4/2024 was again crossed with a line and was changed to 7/10/2024. The untitled facility document posted indicated the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: a. For Day Shift 1. Registered Nurses (RNs) 2. Licensed Vocational Nurses (LVNs) 3. Certified Nurse Assistants (CNAs) 4. Restorative Nursing Assistants (RNAs) 5. Treatment Nurses (TX) 6. Minimum Data Set Nurse (MDS) b. For Evening Shift 1. RNs 2. LVNs 3. CNAs c. For Night Shift 1. RNs 2. LVNs 3. CNAs However, the total actual hours worked by each category of licensed and unlicensed nursing staff directly responsible for resident care per shift was blank. During an observation on 7/10/2024 at 9:32 a.m. observed in NS 1, a document titled “Census and Direct Care Service Hours Per Patient Day (DHPPD)” dated 7/9/2024 posted beside the facility document (untitled). The DHPPD form dated 7/9/2024 indicated actual total direct care service hours for 7/9/2024 and actual total CNA direct care service hours for 7/9/2024. During a concurrent observation and interview on 7/10/2024 at 10:10 a.m., with the Vice President of Operations (VPO), the VPO reviewed the untitled facility document initially dated 6/8/2024, currently dated 7/10/2024 and the DHPPD document dated 7/9/2024 posted in NS 1. The VPO stated that the information posted currently did not indicate the total actual hours worked by each category of licensed and unlicensed nursing staff directly responsible for resident care per shift for 7/10/2024. The VPO further stated that the untitled facility document had been posted since 6/8/2024 and was only updated twice (7/4/2024 and 7/10/2024) utilizing the same document. During an interview with the Director of Nursing (DON) on 7/10/2024 at 12:39 p.m., the DON stated that the facility should post the nursing staffing information on a daily basis and should reflect the total actual hours worked by each category of licensed and unlicensed nursing staff directly responsible for resident care per shift daily. The DON stated the total actual hours worked by each category of licensed and unlicensed nursing staff directly responsible for resident care per shift were not posted since 6/8/2024. A review of the facility’s policy and procedure titled “Posting Direct Care Daily Staffing Numbers” dated 11/20/2022, last reviewed on 2/29/2024, indicated, “Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents…. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format… 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 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 in the facility 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.