Health inspection·March 5, 2025

§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. §483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. §483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/22/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate two complaints regarding quality of care. The facility failed to follow its policy and procedure of meeting the staff posting requirements by failing to ensure current staffing information were posted and placed in a visible and prominent place daily. As a result, the total number of staff and the actual hours worked by staff in the facility were not readily accessible to residents and visitors. During a concurrent observation and interview on 1/22/2025 at 11:55 a.m. with the Director of Nursing (DON), the projected Direct Care Service Hours Per Patient Day (DHPPD refers to the actual hours of work performed per patient day by a direct caregiver), dated 1/21/2025 and the actual DHPPD, dated 1/16/2025, were observed posted at the facility lobby. The DON stated the posted projected and actual DHPPD were not current. The DON stated the DHPPD were posted on all nurse stations. The projected DHPPD, dated 1/21/2025, was observed posted at nurse station 1. There was no posted actual DHPPD observed at nurse station 1. During a concurrent observation and interview on 1/22/2025 at 11:57 a.m. with the Director of Nursing (DON), the projected DHPPD, dated 1/21/2025, was observed posted at nurse station 2. There was no posted actual DHPPD at nurse station 2. The DON stated the DHPPD should have been posted at the nurse station at the start of the shift. During a concurrent observation and interview on 1/22/2025 at 11:58 a.m. with the Director of Nursing (DON), the projected DHPPD, dated 1/21/2025, was observed posted at nurse station 3. There was no posted actual DHPPD at nurse station 3. The DON stated the DHPPD should have been posted at the nurse station at the start of the shift. During a concurrent observation and interview on 1/22/2025 at 11:59 a.m. with the Director of Nursing (DON), the projected DHPPD, dated 1/21/2025, was observed posted at nurse station 4. There was no posted actual DHPPD at nurse station 4. The DON stated the DHPPD should have been posted at the nurse station at the start of the shift. During a concurrent observation and interview on 1/22/2025 at 12 p.m. with the Director of Nursing (DON), The DON stated there was no posted projected and actual DHPPD observed at nurse station 5. The projected DHPPD, dated 1/22/2025, was found in the station 5 assignment folder. The DON stated the DHPPD should have been posted at the nurse station at the start of the shift. During an observation on 1/22/2025 at 12:03 p.m., the projected DHPPD, dated 1/22/2025, for station 3 and station 4 were observed in the stations’ assignment folder. During an interview on 1/22/2025 at 12:05 p.m., the DON stated the payroll staff, charge nurse, or the Director of Staff Development (DSD) should post the DHPPD every morning. The DON stated the DHPPD were posted to inform the residents and visitors that the facility was adequately staffed to provide resident care and services. During a record review of the facility’s policy and procedure (PnP) titled, “Posting Direct Care Daily Staffing Numbers,” last reviewed on 4/18/2024, the PnP indicated within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nursing personnel 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 facility failed to follow their policy and procedure of meeting the staff posting requirements by failing to ensure current staffing information were posted and placed in a visible and prominent place daily. As a result, the total number of staff and the actual hours worked by staff in the facility were not readily accessible to residents and visitors. The above violation had direct or immediate relationship to the health, safety, or security of the residents in the facility.