Health inspection·January 24, 2025

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 12/17/2024, 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 for two of two days (on 12/17/2024 and on 12/18/2024) as indicated in the facility’s policy and procedure (P&P) on “Nurse Staffing Information”. 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 12/17/2024 at 3:00 p.m., observed in the facility’s lobby, a facility document titled, “Posted Nursing Hours for Direct Care Staff”, dated 12/17/2024. During an interview on 12/17/2024 at 4:28 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that the nursing hours posted in the lobby are projected (expected) hours. During a concurrent observation, interview, and record review on 12/17/2024 at 5:06 p.m., with the Director of Nursing (DON), observed the facility’s document titled, “Posted Nursing Hours for Direct Care Staff,” dated 12/17/2024, posted in the facility’s lobby. The DON stated that the posted document is the facility’s nursing projected hours. During an interview on 12/18/2024 at 12:42 p.m., with Payroll 1, Payroll 1 stated that Payroll 1 is responsible for calculating the facility’s actual nursing hours worked daily. Payroll 1 stated that actual nursing hours are calculated the following day for the day prior to ensure that the nursing hours are calculated accurately. Payroll 1 stated that the daily nursing hours posted in the lobby are projected nursing hours for the current day, not actual hours. During a follow-up interview on 12/18/2024 at 1:06 p.m., with Payroll 1, Payroll 1 stated that Payroll 1 has not calculated the actual nursing hours for direct care staff for 12/17/2024 and 12/18/2024. Payroll 1 stated that 12/18/2024’s actual nursing hours will be calculated tomorrow, 12/19/2024. During an interview on 12/18/2024 at 1:09 p.m., with the DON, the DON stated that the nursing hours should be calculated daily. The DON stated that today’s (12/18/2024) nursing hours will be calculated tomorrow. The DON further stated that the DON does not deal with posted nursing hours and just signs them the following day. During a concurrent observation, interview, and record review on 12/18/2024 at 1:20 p.m., with the DON, observed the facility’s document titled, “Posted Nursing Hours for Direct Care Staff,” dated 12/18/2024, posted in the facility’s lobby. The DON stated that the posted document is the facility’s nursing projected hours, not actual hours. The DON stated that it is important to post nursing hours because it will show staff, visitors, and residents that the facility is well staffed. During a review of the facility-provided policy titled, “Nurse Staffing Information,” reviewed 7/30/2024, the policy indicated the 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. The information recorded on the form shall include the following: a. The name of the facility; b. The current date (the date for which the information is posted); c. The resident census at the beginning of the shift for which the information is posted; d. Twenty-four (24)-hour shift schedule operated by the facility; e. The shift for which the information is posted; e. Type (RN [Registered Nurse], LVN [Licensed Vocational Nurse], or CNA [Certified Nursing Assistant]) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff); g. the actual time worked during that shift for each category and type of nursing staff; and h. Total number of licensed and non- licensed nursing staff working for the posed shift. Within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completed the Nurse Staffing Information form. The charge nurse completes the form and posts the staffing information in the location(s) designated by the administrator. 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 for two of two days (on 12/17/2024 and on 12/18/2024) as indicated in the facility’s P&P on “Nurse Staffing Information”. 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.