Health inspection·July 30, 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 6/13/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the revisit for its Annual Recertification Survey. 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 were posted daily (6/14/2024) as indicated in the facility's policy and procedure (P&P) on Direct Care Daily Staff 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 6/14/2024 at 9:40 a.m., observed posted next to the Director of Nursing's (DON) office, the following documents: Facility document titled, "Census and Direct Care Service Per Patient Day (DHPPD)" dated 6/12/2024 and facility document DHPPD, dated 6/14/2024. During a concurrent observation, interview, and record review on 6/14/2024 at 9:45 a.m., with the Director of Staff Development (DSD), reviewed the facility document DHPPD dated 6/12/2024 and facility document DHPPD dated 6/14/2024. The DSD stated that the facility posts both projected hours and actual hours. The DSD observed posted next to the DON's office, the facility document DHPPD, dated 6/12/2024. The DSD stated that the DHPPD dated 6/12/2024 posted are the actual hours of 6/12/2024. The DSD observed posted next to the DON's office, the facility document DHPPD, dated 6/14/2024. The DSD stated that the DHPPD dated 6/14/2024 are projected hours. When asked who was responsible for posting nursing hours, the DSD stated that the Assistant Director of Staff Development (ADSD) is responsible for posting nursing hours. During a concurrent observation and interview on 6/14/2024 at 9:47 a.m., with the ADSD, the ADSD stated that she is responsible for calculating the facility's actual hours worked by licensed and unlicensed nursing staffing daily. The ADSD stated that the actual staffing hours worked for the day are not calculated until the following day to ensure that the nursing hours are calculated accurately. The ADSD further stated that the daily nursing staffing hours posted next to the DON's office are projected nursing hours for the day and not the actual hours. The ADSD continued to state that she will change the current posting (6/12/2024) to reflect the date, 6/13/2024. During a concurrent interview and record review on 6/14/2024 at 10:01 a.m., with the DSD, the DSD stated that the DHPPD posted next to the DON's office are dated 6/13/2024 and 6/14/2024. The DSD stated that the DHPPD hours posted with a date of 6/13/2024 are actual hours and the DHPPD dated 6/14/2024 are projected hours. When asked of the importance of posting actual nursing hours, the DSD stated that actual nursing hours should be posted to show visitors and residents that the facility is in compliance with the nursing hours regulation. A review of the facility's policy and procedure titled, "Posting Direct Care Daily Staffy Numbers," last reviewed 1/11/2024, indicated our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. Within two (2) hours of the beginning of shift, the number of licensed nurses and unlicensed nurses directly responsible for resident care is posted. 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 were posted daily (6/14/2024) as indicated in the facility's policy and procedure (P&P) on Direct Care Daily Staff 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.