Health inspection·July 18, 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 6/3/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about facility staffing. 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 (on 6/3/2024 and 6/4/2024) 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 6/3/2024 at 3:30 p.m., observed in front of the Admission's Office, a facility document titled "Daily Nurse Staffing Information", dated 6/3/2024. During an observation on 6/4/2024 at 12:30 p.m., observed in front of the Admission's Office, a facility document titled "Daily Nurse Staffing Information", dated 6/4/2024. During a concurrent observation, interview, and record review with the Nursing Staffing Coordinator (NSC) on 6/4/2024 at 12:47 p.m., the NSC observed the facility's document titled "Daily Nurse Staffing Information", dated 6/4/2024 posted and framed in front of the Admission's Office. The NSC stated that NSC is responsible for posting daily nursing staffing hours (licensed and unlicensed). The NSC continued to state that the facility posting of the Daily Nurse Staffing Information included only projected hours and not the actual hours. During an interview with the Assistant Administrator (AA) on 6/4/2024 at 12:49 p.m., the AA stated that she is responsible for calculating the facility's actual hours worked by licensed and unlicensed nursing staffing daily. The AA 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 AA further stated that the daily nursing staffing hours posted in front of the Admission's Office are projected nursing hours for the day and not the actual hours. The AA stated she was not aware that the actual nursing staffing hours should be posted. During an interview with the Administrator (ADM) on 6/4/2024 at 12:53 p.m., the ADM stated that there is no way to calculate actual hours on the same day. The ADM stated the nursing staffing hours posted are not the daily actual hours but the projected nursing staffing hours. During an interview with the Director of Nursing (DON) on 6/4/2024 at 4:43 p.m., the DON stated that it is important to post the Nursing Hours Per Patient Day (NHPPD) hours because it shows residents and visitors that the facility is compliant with the regulations regarding staffing. A review of the facility's P&P titled "Nurse Staffing Information", last reviewed 4/23/2024, indicated the facility posts staffing information readily available in a readable format to residents and visitors at any given time. Data includes the facility name, current date and the total number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift on a daily basis. The nurse staffing data is posted in a clear and readable format in a prominent place readily accessible to residents and visitors. 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 (on 6/3/2024 and 6/4/2024) 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. The above violations had a direct relationship to the health, safety, or security of all the residents in the facility.