Inaccurate and Inaccessible Nurse Staffing Postings
Summary
The facility did not ensure the nurse staffing posting was accurate and posted in an accessible area, potentially affecting the census of 106 residents. Multiple daily staff postings did not reflect the actual hours of the nursing staff. The postings were placed high on a wall with small text, making them difficult to read. Specific discrepancies were noted on several dates where the Daily Staff Roster did not match the Daily Census/Staffing document. For example, on 4/17/24, the roster did not reflect that an LPN was scheduled as the nurse manager for the day shift, and the night shift showed discrepancies in the number of LPNs scheduled. Similar inconsistencies were observed on 4/18/24, 4/19/24, and 4/27/24, where the number of CNAs and LPNs listed on the postings did not match the actual schedule. These inaccuracies were confirmed through interviews with the scheduler and residents, who also indicated that the postings were difficult to read due to their location and small text size. On 5/2/24, the surveyor interviewed the scheduler, who confirmed that the postings should reflect the actual schedule and be updated accordingly. The scheduler acknowledged the discrepancies and provided explanations for the mismatches, such as call-ins and errors in updating the postings. Residents interviewed also confirmed that they could not read the postings due to their height and small text. The scheduler admitted that the postings were created the day before and sent to the night nurse, with charge nurses responsible for updating them by 2 PM on the day of the posting. However, this process was not consistently followed, leading to the observed discrepancies and accessibility issues.
Penalty
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The facility did not consistently post nurse staffing data at the beginning of each shift, nor did it include the required resident census on the posted forms. Staffing forms were often completed only once per day, and there was no designated staff to post them on weekends. Interviews revealed that the DON and other staff were unaware of the requirement to post this information each shift, and there was no facility policy in place to ensure compliance.
Daily nurse staffing information was not updated to reflect the current day and did not include the required census number. A CNA confirmed the posting was outdated and incomplete, noting that the scheduler responsible for updates was on vacation. This issue was identified during a complaint investigation and had the potential to affect all residents.
The facility did not consistently post daily nurse staffing information with all required details, such as facility name, resident census, and actual hours worked by licensed and unlicensed staff. Staff postings were often incomplete, undated, or missing, and this issue was confirmed by interviews with HUCs, the DON, and the Administrator.
The facility did not update or post current daily nurse staffing information at the front desk, as required, with staff and DON confirming that the information displayed was several days out of date. This issue was identified during a complaint investigation and had the potential to affect all residents.
The facility did not update the daily nurse staffing information as required, with the posted information reflecting the previous day. The DON confirmed the information was not current at the time of observation, potentially affecting all residents.
Surveyors found that daily nurse staffing information was not posted in the Cornerstone Cottage, as required. This was confirmed by the Administrator and affected all residents living in that area of the facility.
Failure to Post Required Nurse Staffing Data and Resident Census Each Shift
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily at the beginning of each shift, including weekends, and that the posted information contained the required resident census. Review of daily staffing forms over a two-and-a-half-month period revealed that the resident census was not documented for each shift, and on multiple occasions, the staffing form was either missing or incomplete. Observations confirmed that the posted forms did not include the resident census and, at times, were not posted at all. Interviews with the DON and other staff indicated a lack of awareness regarding the requirement to post staffing data at the start of each shift and to include the resident census. The DON reported that staffing forms were typically completed and posted once per day during weekdays, with projected staffing posted for weekends, but no one was designated to post the forms on weekends. Corporate staff confirmed there was no policy in place for posting nurse staffing data, and the facility relied on federal regulations. These practices had the potential to affect all 90 residents in the facility.
Failure to Timely and Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted both timely and accurately. On the morning of 06/10/25, the posted staffing information was observed to be for the previous day, 06/09/25, and did not include the facility census as required. During an interview at the time of observation, a CNA confirmed that the information had not been updated for the current day and that the scheduler, who was responsible for updating the posting, was on vacation. The CNA also verified that the census number was missing from the displayed information. This deficiency was identified incidentally during a complaint investigation and had the potential to affect all 75 residents in the facility.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted as required. Observations and interviews revealed that the daily staff postings did not include essential information such as the facility name, resident census, and the actual hours worked by licensed and unlicensed nursing staff. Instead, postings only listed staff assignments, and some documents were undated or incomplete. Health Unit Coordinators (HUCs) confirmed that several postings were missing required details, and some could not be located for specific dates. Further interviews with the Director of Nursing and the Administrator confirmed that the expectation was for staff postings to be completed correctly every day, both in the morning and evening. However, the documentation provided for review consistently lacked the necessary information, affecting all 54 residents currently residing in the facility. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nursing staffing information was posted as required, potentially affecting all 63 residents in the facility. Multiple observations on different days revealed that the staffing information displayed at the front receptionist desk was outdated, consistently showing the date 05/12/25 instead of the current date. Staff interviews with both the receptionist and the Director of Nursing confirmed that the posted staffing information had not been updated. This deficiency was identified during the course of a complaint investigation.
Failure to Timely Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a timely manner. On the morning of 05/05/25, an observation revealed that the staffing information displayed was for the previous day, 05/04/25, and had not been updated for the current day. During an interview at the time of observation, the DON confirmed that the posted information was outdated and had not yet been updated. This deficiency was identified during a complaint investigation and had the potential to affect all 132 residents in the facility.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted as required in the Cornerstone Cottage. Upon arrival and during subsequent observations, surveyors noted that there was no daily nurse staffing information displayed in any of the common areas or hallways of the Cornerstone Cottage. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the required nurse staffing information was not posted. The lack of posted staffing information affected all ten residents residing in the Cornerstone Cottage at the time of the survey, with the facility census being seventeen.
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