Health inspection·April 5, 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 2/23/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the 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 was posted daily and was placed in a visible and prominent place as indicated in the facility’s policy and procedure (P&P) on Posting Direct Care Daily Staffing Number. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors. During an observation on 2/23/2024 at 10:31 a.m., a projected, not an actual Direct Care Services Hours Per Patient Day (DHPPD) was observed posted at the receptionist area and on the counter of Nursing Station 1. During an observation on 2/24/2024 at 8:18 a.m., a projected, not an actual DHPPD was observed posted at the receptionist area and on the counter of Nursing Station 1. On 2/24/2024 at 4:28 p.m., during an interview, the Director of Staff Development (DSD) stated that the facility posting of the DHPPD included only projection hours and not the actual hours. DSD stated he did not know if the actual hours should be posted. On 2/25/2024 at 2:57 p.m., during an interview, the DSD stated that he checked the facility's P&P and the actual DHPPD should be posted. A review of the facility's P&P titled, "Posting Direct Care Daily Staffing Numbers" reviewed on 1/3/2024, indicated the facility would post on a daily basis for each shift the nurse staffing daily, including the number of nursing personnel responsible for providing direct care to residents ... the information recorded on the form shall include the following: 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 and was placed in a visible and prominent place as indicated in the facility’s P&P on Posting Direct Care Daily Staffing Number. As a result, the total number of staff and the actual hours worked by the staff 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.