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F0725
E

Failure to Meet Minimum CNA Staffing Hours on Two Weekend Days

Covina, California Survey Completed on 04-19-2025

Penalty

Fine: $54,900
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the required 2.4 Certified Nursing Assistant (CNA) direct care hours per patient day on two weekend days during the first quarter of 2024. Payroll Based Journal (PBJ) Staffing Data Reports and supporting documentation confirmed that on these dates, the actual CNA hours per patient day were 2.04 and 2.15, both below the mandated minimum. The Director of Staff Development (DSD) verified these figures during a review of staffing assignment sheets, sign-in sheets, and census data, and confirmed that the data was accurately reported to the California Department of Public Health (CDPH). During interviews, the DSD and the Director of Nursing (DON) acknowledged the shortfall in CNA hours and indicated that the facility had been struggling to meet staffing requirements during the specified period. The facility's policies and procedures require compliance with minimum staffing standards, including the 2.4 CNA hours per patient day, but these standards were not met on the identified dates. No specific residents or their medical conditions were mentioned in relation to the deficiency.

See complete original report
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