Failure to Update Nurse Staffing Information on Each Shift
Summary
The facility failed to update the posted nurse staffing information on each shift for 2 of 5 days during the onsite recertification survey. On 3/17/24, the daily posted nurse staffing and information sheet was observed to be dated 3/14/24. On 3/19/24, the sheet was not updated at the 7:00 PM shift change and contained the same information as earlier in the day. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that the facility's practice was to update the staffing sheet every 24 hours, not at each shift change, and that the ADON was unaware of the requirement to update the information on each shift. The ADON admitted to forgetting to update the information on 3/16/24 and 3/17/24, and the Unit Manager was unavailable for an interview to explain why the information was not updated on 3/15/24. The Administrator confirmed that the facility operates on 12-hour shifts and that the posted nurse staffing and information sheet was only changed out every 24 hours. The Administrator also stated that the nursing management department was responsible for posting the daily nurse staffing information and that they worked as a team to ensure it was updated daily. However, the posted nurse staffing sheet was only updated throughout the day to reflect actual working hours when there were call outs. The ADON and Unit Manager were identified as the individuals responsible for posting the nurse staffing and information sheet daily.
Penalty
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The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
The facility did not ensure that daily postings of nurse staffing accurately reflected the actual hours worked by licensed and unlicensed nursing staff. Although facility policy required posting direct care daily staffing numbers for each shift, surveyors found that posted staffing information over several months was not adjusted when scheduled hours differed from actual hours worked. The RNC and DON acknowledged that they did not update the posted staffing with actual hours, only the internal daily assignment sheets, resulting in inaccurate publicly posted staffing information for all shifts.
The facility failed to ensure daily nurse staffing postings were accurate and complete. Surveyors observed multiple posted staffing sheets that did not include total hours worked and, at one point, did not list the facility name. Review of additional dates showed the same omission of total hours worked. An administrative nurse reported that a night-shift nurse completed and posted the next day’s staffing sheet and indicated that a column labeled "actual hours" was intended to represent total hours worked, despite the facility’s written policy requiring clear computation and recording of staffing levels and census information on the Daily Nurse Staffing form.
The facility failed to accurately complete and post daily nurse staffing information for all shifts, resulting in multiple days where RN, LPN, or CNA staffing data were missing or entire staffing sheets were not available. On several occasions, posted information lacked RN or LPN data for specific shifts, omitted CNA data for all shifts, or showed only one RN for part of a shift with no other licensed nurses listed. The Staffing Coordinator later acknowledged that these staffing sheets and data should not have been missing but were, affecting the ability of residents, their representatives, visitors, and others to review accurate staffing levels.
The facility failed to ensure daily posting of nurse staffing information in a visible area for residents and visitors when the designated Scheduler was not on duty. Surveyors observed that the posted staffing sheet was several days out of date, and interviews revealed that the Scheduler, who did not work weekends, was solely responsible for creating and posting these sheets. The Scheduler acknowledged that no process existed to ensure postings occurred during her absence and that she had not discussed such a process with the Administrator. The Administrator confirmed reliance on the Scheduler and was unaware that staffing information was not being posted when the Scheduler was out of the office.
Surveyors found that daily nurse staffing information was not consistently posted or retained as required. Over an 18‑month review period, multiple days of staffing records were missing, and the sheet displayed during observation was not for the current date. Staff interviews showed that an administrative staff member was responsible for weekday postings and record retention, while charge nurses were expected to post and update prefilled sheets on weekends. A changeover in the personnel responsible for maintaining these records contributed to the inability to locate all required historical staffing sheets, despite a written policy requiring timely posting and 18‑month retention of nurse and CNA staffing data.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurate and posted daily for each shift, as required by its own policy. The facility’s “Staffing, Sufficient and Competent Nursing” policy, revised April 2025, stated that direct care daily staffing numbers for each shift must be posted in the facility. On 4/13/26, surveyors reviewed the daily postings of licensed and unlicensed nurse staffing for the period 11/1/25 through 4/11/26 and found there were no adjustments made to the posted staffing when the scheduled hours did not match the actual hours worked. During an interview on 4/13/26 at 11:37 AM, the RNC and DON confirmed that the facility does not update the daily posted staffing with actual hours worked and instead only adjusts the time on the daily assignment sheets. This practice resulted in posted staffing information that did not reflect the actual direct care nursing personnel responsible for resident care for each shift, affecting all residents, their representatives, visitors, and others who might review the facility’s staffing levels.
Inaccurate and Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that its posted daily nurse staffing sheets contained accurate and complete information, including the facility name and total hours worked, as required. On 04/13/26 at 08:00 AM, the posted staffing sheet did not include the total hours worked. On 04/14/26 at 09:30 AM, the posted staffing sheet again lacked the total hours worked and also did not list the facility name. Review of prior daily staffing sheets dated 05/13/25 and 03/18/26 showed that these postings also did not include the total hours worked. During an interview on 04/14/26 at 11:48 AM, Administrative Nurse D explained that the night shift nurse completed the next day’s staffing sheet and posted it before the start of the next shift, and stated that the column labeled “actual hours” represented the total hours worked. The facility’s policy, “Daily Nurse Staff Posting,” dated 11/28/17, required that at the beginning of each shift the charge nurse compute the number of full-time equivalents on duty, record this on the Daily Nurse Staffing form, and post it in designated locations so it could be easily seen and read, and also required that the facility census be recorded and updated with any admissions or discharges throughout the day. This deficiency centers on the inconsistency between the facility’s policy requirements for daily nurse staffing postings and the actual content of the posted forms, which repeatedly lacked required elements such as total hours worked and, on at least one occasion, the facility name.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift, as required. On review of the posted daily staffing sheets on 3/30/26 at 4:17 PM, surveyors identified multiple dates with missing sheets or incomplete staffing data: on 5/6/25 there was no RN or LPN data listed for the day and evening shifts; on 9/8/25 there was no RN or LPN data listed for the evening shift; on 9/19/25 there was no CNA data listed for the day, evening, or night shifts; and on 12/7/25, 12/20/25, and 12/21/25 the daily staffing sheets were missing entirely. In addition, on 12/22/25 the posted information showed only one RN for 8 hours on the evening shift with no licensed nurses scheduled for the day or night shifts. On 3/31/26 at 4:00 PM, the Staffing Coordinator acknowledged that the missing staffing data and sheets for the identified dates should not have been missing but were. This deficient practice had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who might seek to review the facility’s staffing levels, by preventing accurate review of nurse staffing information for the affected dates and shifts.
Failure to Ensure Daily Posting of Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to post required daily nurse staffing information in a location visible to residents and visitors on one of four survey days, and the lack of an effective process to ensure this information was posted every day, including weekends. On a Sunday at 10:00 AM, surveyors observed that the daily staffing information sheet at the reception desk was dated three days earlier, indicating that current staffing information for the intervening days had not been posted as required. No residents or specific patient conditions were mentioned in relation to this deficiency. Interviews and record reviews showed that the Scheduler was solely responsible for preparing and posting the daily staffing information sheets and did not work on weekends or certain weekdays. The Scheduler acknowledged that she had not completed or posted the daily staffing information sheets for the days she was off and stated that there was no process in place to ensure postings occurred in her absence. She also reported that she had not discussed implementing such a process with the Administrator. The Administrator confirmed that the Scheduler was responsible for posting the staffing sheets and stated she was unaware that postings were not occurring when the Scheduler was out of the office, and that the facility had no process to ensure daily postings when the Scheduler was absent or on weekends.
Failure to Post and Retain Required Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to consistently post and retain daily nurse staffing information as required by regulation and facility policy. Surveyors reviewing 18 months of records on 03/24/26 found that the facility lacked any posted staffing information from 08/01/25 through 11/14/25, as well as additional specific missing days in November and December 2025, January and February 2026, and March 2026. On 03/24/26 at 1:49 PM, observation showed that the daily posted staffing sheet on display was dated 03/23/26 instead of the current date. The facility’s written policy from October 2021 required that within two hours of the beginning of each shift, the numbers of licensed nurses and CNAs directly responsible for resident care be posted in a prominent, accessible location in a clear and readable format, and that records of staffing information for each shift be kept for at least 18 months or longer if required by state law. Interviews with staff clarified how the posting process was intended to work and revealed gaps in implementation. On 03/31/26, an LN stated that an administrative staff member was responsible for posting the daily staffing sheets during the week, and that on weekends the sheets were prefilled and posted by the charge nurse, who would adjust them if needed. An administrative nurse confirmed that the same administrative staff member was in charge of both posting and retaining the daily staffing information, and that on weekends the charge nurse was responsible for posting and updating the prefilled sheets. Another administrative staff member reported there had been a changeover in the staff responsible for maintaining the daily posted staffing sheets and acknowledged she had not been able to locate all of the required records from the past 18 months. At the time of the survey, the facility had a census of 54 residents and a sample of 12 residents, but the deficiency centered on the facility’s failure to post and retain required staffing information rather than on specific resident clinical issues.
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