Inaccurate Nurse Staffing Information and Record Retention Failure
Summary
The facility failed to ensure the accuracy of its daily nurse staffing information, as required by regulations. During a review of the staff posting forms, it was found that the total count of direct care nursing staff and their hours inaccurately included nursing staff with administrative duties and their administrative hours. For instance, on one occasion, the count of Registered Nurses (RNs) included hours from an RN Unit Manager, which should not have been counted as direct care hours. Similarly, Licensed Practical Nurses (LPNs) and RNs with administrative duties were incorrectly included in the direct care staff totals. The facility's administrator acknowledged that these inaccuracies were against the guidelines set by the Centers for Medicare & Medicaid Services (CMS), which require reporting based on the employee's primary role. Additionally, the facility did not retain the staffing posting forms for the required 18 months. During the survey, it was revealed that the facility did not maintain these forms, as they were sent to the corporate office for data entry and then disposed of. The facility's Medical Records representative confirmed that they were unaware of the requirement to keep these forms. The administrator also agreed that the original staffing posting forms should have been maintained, acknowledging the facility's failure to comply with this requirement.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Nurse Staffing Posting and Missing Census/Hours: The facility failed to post required daily nurse staffing data in a clear, accessible format with the correct date, actual hours worked, and resident census. Surveyors found postings with missing actual hours, missing census, and at least one missing day, while the ADON stated postings were placed behind each other and no staff were assigned to verify the correct date. Record review also showed repeated missing actual hours and census across multiple months, and the ADM stated there was no policy for nurse staffing posting.
Missing Daily Nurse Staffing Information: The facility failed to post complete daily staffing information on the Daily Staffing sheets. The sheets reviewed did not include the actual hours worked by RNs, LPNs, and CNAs, and many also did not list the facility name. The Administrator and RNC acknowledged the required information was missing from the staffing sheets.
Failure to Post Actual Nurse Staffing Hours: The facility posted nurse staffing sheets that listed staff counts and scheduled hours, but not the actual hours worked. Administrative staff stated the actual hours were recorded on a signed log kept in a lobby binder, but that log was not posted. The facility policy required nurse staffing information to be readily available and posted in a prominent, readable location.
Failure to Post Required Daily Staffing Information: The facility did not post the required daily census and actual DHPPD information for the prior day, even though only the next day’s estimated staffing form was displayed in the posting area. The ADM said the Scheduler posted the forms before leaving, but the Scheduler stated she had only been instructed to post the next day’s estimated form, not the prior day’s actual census and DHPPD data. The DON confirmed the required prior-day form was not posted, despite the facility policy requiring daily staffing postings in a prominent location accessible to residents and visitors.
Inaccurate daily nurse staffing information was posted in the window at the main entrance and did not reflect the actual resident census or the hours worked by RNs, LPNs, CMAs, and CNAs. Staff said receptionists completed the posting each morning, used the schedule inconsistently, did not know which nurses were RNs or LPNs, and did not update the posting as staffing changed. The facility had no policy for the posting, and the Facility Assessment called for staffing to be adjusted based on census and resident care needs.
Nurse staffing information was not posted in a prominent, readily accessible location on four of four nursing units. Observation and interview with the DON found the staffing sheet posted only on [NAME] Street inside the nursing station, where it was not visible to residents or visitors, and the DON confirmed the posting requirement was not met.
Incomplete Nurse Staffing Posting and Missing Census/Hours
Penalty
Summary
The facility failed to ensure that Nurse Staffing Information was posted daily with the required data elements, including the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, as well as resident census. Observations on 8/09/2026 at 11:50 AM and 11:51 AM found the staffing posting on the wall in a clear 8 by 11 folder, but the posting dated 8/7/2026 was missing actual hours, the posting dated 8/10/2026 had no actual hours and no census, and the 8/9/2026 posting was missing for the day. The ADON stated she posted the next day’s staffing information before leaving and that the 8/9/2026 posting was behind the 8/7/2026 posting, with no staff assigned to ensure the correct date was posted. Record review showed multiple staffing postings from October through December 2025 were missing actual hours worked. January 2026 postings for 1/1 through 1/28 and 1/30 through 1/31 were missing actual hours, and the 1/29/2026 staffing sheet was missing. February 2026 postings for 2/2, 2/5, 2/6, and 2/8 were missing actual hours, while 2/9 and 2/28 were missing census. March 2026 postings for 3/1 through 3/30 and 3/28 through 3/30 were missing census. May 2026 postings for 5/23, 5/24, 5/25, 5/26, 5/28, 5/30, and 5/31 were missing census, and June 2026 postings for 6/17, 6/20, 6/21, 6/22, 6/24, 6/27, 6/28, and 6/30 were missing census. The ADM stated there was no policy for Nurse staffing posting, and the DON stated she did not believe missing or incorrect staffing information could affect residents and visitors.
Missing Daily Nurse Staffing Information
Penalty
Summary
Nurse staffing information was not accurately posted daily for each shift. During observation and staff interview, the facility failed to ensure the Daily Staffing sheets for 5/1/26 through 8/4/26 included the required actual hours worked by RNs, LPNs, and CNAs, and many of the sheets also did not document the facility's name. The State Operation Manual, Appendix PP, S483.35(g), requires daily posting of the facility name, current date, total number and actual hours worked by RN, LPN/LVN, and CNA staff directly responsible for resident care per shift, and resident census. On 8/5/26 at 11:00 AM, the surveyor observed the missing information on the staffing sheets, and at 2:30 PM the Administrator and RNC stated the required information was missing from the daily staffing sheets.
Failure to Post Actual Nurse Staffing Hours
Penalty
Summary
The facility failed to post the required nurse staffing information because the staffing sheets posted from 02/02/2025 to 08/02/2026 did not list the actual hours worked by staff. Survey review found the posted sheets showed the number of staff and scheduled hours, but not the actual hours worked, and the facility was unable to provide posted staffing documentation containing all actual hours worked. During interviews, Administrative Staff A stated the staff coordinator completed the daily posting forms and that a posted staffing sheet had been created to meet state requirements. Administrative Staff A also stated that actual staff hours were available on a log requiring staff signatures, but that the log was kept in a binder in the lobby and was not posted. The facility policy stated nurse staffing information was to be readily available in a readable format and posted in a prominent place accessible to residents, staff, and visitors.
Failure to Post Required Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the required daily patient census and actual direct care service hours per patient day information was posted for 7/29/26 for a facility census of 178. On 7/30/26 at 1:19 p.m., observation of the designated staffing information posting location in a hallway near the front lobby showed only the DHPPD form dated 7/30/26 with estimated direct care service hours per patient day; the form reflecting the average daily census and actual direct care service hours calculations for 7/29/26 was not displayed. During interviews, the Administrator stated the Scheduler posted the required census and DHPPD forms in the evening before leaving the facility and confirmed the Scheduler was directly supervised by the Administrator. The Scheduler stated the Administrator instructed her to post the next day’s daily census and estimated direct care service hours form daily, but she had not been instructed to post the previous day’s DHPPD form showing the average daily census and actual direct care service hours calculations, so she did not post it. The DON also confirmed the required DHPPD form for 7/29/26 was not posted and acknowledged that the previous day’s average daily census and actual direct care service hours calculations must be posted daily. The facility policy required daily posting of staffing data, including resident census, in a prominent place readily accessible to residents and visitors.
Inaccurate daily nurse staffing posting
Penalty
Summary
The facility failed to ensure the daily posted nurse staffing information reflected the actual resident census and the hours worked by RNs, LPNs, CMAs, and CNAs per shift, and the posting was not kept accurate throughout the day. On 7/28/26 at 8:30 a.m., surveyors observed the resident census and daily nurse staffing information posted in the window at the main entrance. The posting listed the date, resident census, and the number of nursing personnel and total hours scheduled to work for that day. However, review of the July 2026 nursing schedule showed no RN was scheduled for 7/14/26 and 7/22/26, while the daily posted staffing information for both dates showed one RN scheduled for a 12-hour day shift and one RN scheduled for a 12-hour night shift. Interviews showed the posting process was not based on actual staffing information. RN medication nurse H said call-in information was given to DON B, staff development RN D, or administrator A, and expected it to be relayed to receptionist U, who posted the staffing information, but H did not know whether it was updated during the day. Receptionist U said she prepared the posting each morning, used the schedule for CNAs and CMAs, did not know which nurses were RNs or LPNs, and had been trained to always write that one RN and two LPNs were scheduled for the day and night shifts. She also said she did not update the posting as the census or staffing changed. Staff development RN D and administrator A described staffing coverage expectations and stated that receptionists completed the posting, while administrator A said she was not aware the posting should reflect census and staffing updates throughout the day. The provider had no policy for posting the daily resident census and nurse staffing information, and the Facility Assessment indicated staffing should be evaluated and adjusted based on resident census and care needs.
Nurse Staffing Information Not Posted in Accessible Location
Penalty
Summary
The facility failed to ensure that current and accurate nurse staffing information was posted in a prominent place readily accessible to residents, staff, and visitors on four of four nursing units. During observation and interview with the DON, nurse staffing information was found posted only on the nursing unit named [NAME] Street. The posting was located inside the nursing station and was not visible to residents or visitors. In a later interview, the DON confirmed that the facility had failed to ensure the staffing information was posted in a prominent and accessible location.
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