Inaccurate Staffing Records and Incomplete Record Maintenance
Summary
The facility failed to ensure the accuracy and currency of the Daily Staffing Posting information, which had the potential to affect all residents. During a review on March 25, 2024, it was found that nursing administrative staff hours were incorrectly included in the Nursing Direct Care hours on several dates. The Corporate Administrator acknowledged that the facility was using administrative staffing hours as direct care hours, based on the misunderstanding that staff helping out with others throughout the day could be counted as direct care. This misunderstanding was clarified during the review of the Centers for Medicare & Medicaid Services policy manual, which specifies that hours should be reported based on the employee's primary role. Additionally, the facility did not maintain the Daily Nurse Staffing Posting Forms for the required minimum of 18 months. It was discovered that the forms did not accurately reflect staff absences due to call-outs and illness, as required by regulatory guidance. The Corporate Administrator admitted that the staff responsible for posting the forms was unaware of the requirement to keep the original forms for 18 months, resulting in the loss of these records. This oversight in maintaining accurate and complete staffing records was acknowledged by the facility's administration.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Daily Nurse Staffing Postings: The facility failed to ensure daily staffing sheets were accurate and posted for each shift. Survey review found missing nurse data, CNA data, and resident census information on multiple dates, and the sheets did not document the actual hours worked by nursing staff. The DON stated the staffing sheets should have been completed correctly but were not.
Inaccurate daily nurse staffing postings were identified when the facility’s daily postings did not match the actual staffing levels shown on the schedules. The DON and administrator stated the postings were completed by the receptionist and were not updated for call-ins, no-shows, or staff picking up shifts. The receptionist and staffing coordinator confirmed the postings were not being adjusted to reflect changes, and review of the schedules and postings showed they did not match.
The facility failed to post accurate nurse staffing information on a daily basis. Surveyors observed staffing sheets posted with future dates, including postings at the main entrance and nursing station, and one posting showed a census that did not match the Resident Listing Report. The DON, Administration, and Staffing Coordinator acknowledged the staffing information was being prepared and posted ahead of time, and the census on the sheet was incorrect.
Failure to post and retain daily nurse staffing information. Observation showed no staffing sheet posted, and an AN stated the staffing information should be easily viewed. The facility also did not keep records of all daily nurse staffing postings for the required 18 months, despite policy stating the information must be readily available to residents, staff, and visitors.
A facility failed to post current and accurate nurse staffing information at the beginning of the shift. The staffing sheet in the lobby showed an outdated date, and the resident census and staffing hours did not accurately reflect the current total hours worked by licensed and unlicensed nursing staff directly responsible for resident care. The NHA confirmed the required staffing and census information was not posted correctly.
Nurse staffing posting was not updated daily and was found posted with outdated dates on multiple observations. NA-A confirmed the posting was outdated, SC-B stated she changed staffing hours for the coming week but did not update the posted sheets until later, and the DON verified the posting should be current so families and visitors could see how many residents were in the facility and how many staff were working.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure nurse staffing information was accurate and posted daily for each shift. During review of the facility daily staffing sheets, the surveyor found missing nurse staffing data and census data on multiple dates, including missing resident census entries and missing nurse and CNA data for specific shifts. The daily staffing sheets also had not documented the actual hours worked by nursing staff. On 6/8/26 at 1:30 PM, the DON stated the daily staffing sheets should have been completed correctly and had not been.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that required nurse staffing information was posted each day with an accurate total number and actual hours worked per shift for licensed and registered staff on each shift. Review of the daily staff postings and staff schedules for the past month showed the postings did not accurately reflect actual staffing levels during each day. The DON and administrator stated the postings were completed by the receptionist and did not reflect changes such as call-ins, no-shows, or staff picking up shifts. The receptionist stated she filled out the posting form from the schedule sent by the staffing coordinator and that no one updated the posting for staffing changes. The staffing coordinator stated she was responsible for the schedule and forwarding daily information to the receptionist and DON, but not the staff posting, and she was not aware of anyone updating the postings to reflect call-ins, no-shows, or picked up shifts. Review of May and June 2026 schedules and postings confirmed they did not match, and the facility policy on daily staff postings was not provided.
Inaccurate Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure accurate nurse staffing information was posted on a daily basis. During observations on 6/1/2026, staffing information dated 6/1/2026 was posted at the main entrance, but the census listed as 103 did not match the Resident Listing Report census of 102. Later that same day, staffing information dated 6/2/2026 was observed posted, and on 6/2/2026 staffing information dated 6/3/2026 was posted at the main entrance. On 6/3/2026, staffing information dated 6/4/2026 was posted at the 100 Hall nursing station near the off-hours facility entrance. During interview, the DON confirmed the staffing information posted was dated 6/4/2026 and stated the scheduler would prepare the staffing information sheet before leaving and corrections would be made the next day. The DON also stated the staffing sheet should not be posted in the front and should be placed behind the current day until the new shift starts. Administration stated the staff coordinator should not post the staffing information the day before and should post the current staffing information for the day. The Staffing Coordinator stated she had been putting the staffing information out before leaving at the end of the day for the following day and did not notice the census was incorrect.
Failure to Post and Retain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing sheet was posted and failed to retain the required 18 months of daily nurse staffing postings. On 06/01/2026 at 07:37 AM, observation showed that no nurse staffing sheet was posted. During an interview on 06/03/2026 at 01:40 PM, Administrative Nurse D stated that staffing should be posted where it could easily be viewed and that the facility did not keep documents of all daily posted nurse staffing from the last 18 months due to high turnover. The facility policy, Nurse Staffing Posted Information dated 02/01/2026, stated that nurse staffing information was to be made readily available in a readable format to residents, staff, and visitors at any given time.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current and accurate nurse staffing information was posted at the beginning of the shift. On observation in the main lobby at the reception desk, the posted nurse staffing information showed an outdated date of 4/3/26, and the resident census and staffing hours did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care for the current date. During an interview, the Nursing Home Administrator confirmed that the facility failed to post the required current facility information for staffing hours and the facility census.
Nurse Staffing Posting Not Updated Daily
Penalty
Summary
The facility failed to ensure the nurse staff posting was posted daily and updated to reflect current staffing. Surveyors observed the posting on multiple occasions and found it dated 5/26/26 on 5/27/26 at 2:15 p.m. and again on 5/28/26 at 6:58 a.m., dated 5/26/25 on 5/27/26 at 4:10 p.m., and dated 5/28/26 on 5/29/2026 at 8:13 a.m. The deficiency affected all 24 residents residing in the facility. During interview, NA-A verified the posting was dated 5/26/26 and stated it was important for families and visitors to see how many staff were working. SC-B stated she changed the nurse staffing hours on Thursdays for the coming week but did not update the posted sheets, and instead made the changes in the computer after they occurred when she returned on Mondays. A review of the next week's schedules showed the census as 24, and one schedule dated 5/30/26 had zeros for all staff listed with a census of 24. The DON verified the nurse staff posting should be posted daily so anyone could see how many residents were in the facility and how many staff were working, and stated it was important so families could have confidence there was enough staff to take care of their family members.
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