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F0732
B

Failure to Accurately Post Daily Nurse Staffing Information

Pasadena, California Survey Completed on 06-05-2025

Penalty

No penalty information released
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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 ensure that the posted Nurse Staffing Information was accurate and updated daily, as required by its policy and procedure. Observations revealed that the staffing information displayed in the front lobby was not current on multiple occasions, with postings showing outdated dates. Specifically, on several days, the posted information did not reflect the actual number of staff present for various shifts in both the subacute and skilled nursing facility units. Record reviews confirmed discrepancies between the posted staffing information and the actual Nursing Staffing Assignment and Sign-in Sheets for those dates and shifts. Interviews with the Director of Staff Development (DSD), Director of Nursing (DON), and Administrator confirmed that the posted information should accurately represent the number of staff working each day to inform residents, visitors, and staff. The facility's policy, revised in October 2022, requires daily posting of the total number and actual hours worked by licensed and unlicensed nursing staff in a prominent location. The failure to maintain accurate and timely postings had the potential to leave residents and visitors uninformed about the actual staffing levels providing direct care.

See complete original report
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