Deficiency in Daily Nurse Staffing Information Posting
Summary
The facility failed to ensure that the daily nurse staffing information included all required details, specifically the total number of licensed and unlicensed nursing staff directly responsible for resident care. During the Recertification Survey conducted from December 12 to December 19, 2024, it was observed that the posted nurse staffing information, located next to the elevators and nursing units, included the facility name, current date, actual hours worked, and resident census, but omitted the total number of nursing staff. This omission was contrary to the facility's policy, which mandates that the posted information should include the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Nurses, and Certified Nurse Aides. Interviews conducted during the survey revealed a lack of awareness and oversight regarding the requirement to post the total number of staff. The Deputy Director of Nursing stated that the Assistant Director of Nursing from each shift is responsible for posting the nurse staffing information, and the current practice was based on hours worked rather than the number of staff. The Director of Nursing admitted that the omission of the total number of staff was an oversight, and the Administrator was unaware of the requirement to include this information. This deficiency was identified under 10 NYCRR 415.13.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: The daily nurse staffing form was revised to include all required elements of posting, specifically, a column for the total number of licensed and unlicensed nursing staff directly responsible for resident care was added to the form that is posted. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Director of Nursing/designee will monitor compliance with the daily posting of nurse staffing to include the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The Educator/designee will provide additional education to all licensed nursing staff on the "Minimum Staffing" policy. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Administrator and Director of Nursing will review and revise as needed policies and procedures related to the posting of staffing. The Educator/designee will provide additional education to all staff involved in the posting of daily nurse staffing to include the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Assistant Directors of Nursing/designee will audit 10% of all Daily Nurse Staffing Forms on a weekly basis for 3 months to ensure that the posted staffing includes the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The Director of Nursing/designee will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow up to ensure 100% compliance. Additional corrective action will be implemented as needed. 5. Responsible Individual: Director of Nursing
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Nurse staffing posting missing resident census. The nurse staff posting observed by the DON office listed nursing hours by shift and discipline, but the census section was blank. The DON confirmed the census should have been included, and facility policy required the resident census at the beginning of the shift to be posted with the staffing information.
Inaccurate daily staffing posting. The facility failed to keep the staffing sheet current and accurate for 2 of 6 days. On one morning, the posting was still dated from the prior Friday, and the Staffing Coordinator said weekend postings were left as blank copies at the reception desk and she was unsure whether receptionists knew how to complete them. She also stated that when an LPN called out, she did not update the posting to show that 2 licensed nurses actually worked the night shift, even though the census was 75.
Failure to Post Daily Nurse Staffing and Census Information: The facility did not post the required daily staffing and census document during facility tours, and the required RN, LPN/LVN, CNA, and census information was not posted at the beginning of each shift. The DON said the task had not been reassigned after the scheduler role changed, and the ADMIN said the posting duty had been missed for the prior two days despite the facility policy requiring the information to be posted within 2 hours of each shift start.
The facility failed to ensure daily nursing staffing postings were accurately completed and posted. Review of staffing sheets showed multiple blank shifts across several months and several dates with no RN identified, including shifts worked by agency nurses. The DON stated charge nurses were responsible for completing the form each shift, but she did not monitor the process, and staff interviews showed inconsistent understanding of who completed the posting.
The facility failed to ensure nurse staffing information was accurate and posted daily for each shift. During review of the daily staffing sheets, the surveyor found the facility name was missing from all of the staffing sheets, and the CCO confirmed it should have been included.
Inaccurate Daily Nurse Staffing Postings: The facility failed to post accurate nurse staffing information at the nursing stations, showing only a combined total of nursing staff per shift instead of the required breakdown of actual hours worked by RN, LVN, and CNA. The DON confirmed the postings were inaccurate and stated the information is intended to inform residents, responsible parties, and visitors about the type, category, and hours of nursing care provided.
Nurse Staffing Posting Missing Resident Census
Penalty
Summary
The facility failed to include the resident census on the nurse staff posting. During an observation on 7/20/26 at 3:46 p.m., the nurse staff posting dated 7/20/26 was observed on a bulletin board by the DON office and showed the total number of nursing staff hours broken down by day, evening, and overnight shifts, with spaces for RN, LPN, TMA, and NA, but the census area was blank. During an interview on 7/20/26 at 4:00 p.m., the DON stated that the night shift was responsible for posting the nurse staff posting and verified that the census area should have been included. The DON also stated that it is important to list the census and staffing so the information is available to residents and visitors. Facility policy titled Posting Direct Care Daily Staffing, dated 9/27/22, required the form to include the facility name, the date, and the resident census at the beginning of the shift, but the direct care daily staffing posting lacked the census information.
Inaccurate Daily Staffing Posting
Penalty
Summary
The facility failed to ensure daily staffing information was accurate and current for 2 of 6 days. Upon surveyor entrance on Monday morning, the staffing posting was still dated Friday and had not been updated before the night shift. During interview, the Staffing Coordinator stated that she posts the staffing sheet every morning Monday through Friday, but on weekends she leaves blank copies at the reception desk and was not sure whether receptionists know how to complete them. She agreed that the Monday morning posting was dated Friday. The Staffing Coordinator also stated that on Friday she had a nurse call out and did not update the staffing posting before the shift to reflect that 2 licensed nurses actually worked the night shift, even though the census was 75 and only one licensed nurse was listed on the posting.
Failure to Post Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to post daily nurse staffing information that included the facility name, current date, total number and actual hours worked by RNs, LPNs/LVNs, CNAs directly responsible for resident care per shift, and the resident census for 2 of 2 days reviewed. During observations on 06/30/2026 at 10:49 a.m. and 12:27 p.m., and again on 07/01/2026 at 09:50 a.m. and 12:50 p.m., surveyors did not observe a document with the daily census and nurse staffing information during facility tours. The report states the required current nurse staffing and census information was not posted at the beginning of each shift on those dates. During interview on 07/01/2026, the DON stated the document should be posted and that she had to verify the task was not overlooked. She said the scheduler position had recently changed to an as-needed, primarily remote role and the task had not been reassigned after that change. The ADMIN stated the document was typically posted after the morning meeting, that the prior Staffing Coordinator had been responsible, and that the task was reassigned to him after the position became empty; he stated the task seemed to have been missed for the prior two days. Record review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, dated revised August 2022, stated the facility will post nurse staffing data daily and, within 2 hours of the beginning of each shift, post the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care in a prominent location.
Incomplete Nursing Staffing Postings
Penalty
Summary
The facility failed to ensure required and accurate nursing staffing information was posted each day. During observation, the daily nursing staffing posting at the nurses station included the required categories for RN, LPN, TMA, and CNA, but review of postings for April through June showed multiple blank shifts and missing RN documentation. In April, 16 shifts were left blank, all on night shift, and an RN was not identified on five dates. In May, 12 shifts were left blank, including 16 night shifts and one evening shift, and on one date an RN in training was listed without another RN identified. In June, 16 shifts were left blank, including night, evening, and day shifts, and an RN was not identified on four dates. The DON stated charge nurses were responsible for completing the staffing posting at the start of each shift and that at least one RN was scheduled for eight consecutive hours every day, with a nurse leader scheduled on day shift Monday through Friday. The DON said the missing RN entries were primarily on shifts worked by agency nurses who likely did not know they needed to complete the form, and stated she did not monitor the process to ensure the form was completed each shift and each day. RN-A stated she had never filled out a staffing posting for a shift she worked, while LPN-A stated the charge nurse completed the posting using the electronic schedule and updated it for call-ins. The facility policy stated the charge nurse was to obtain and complete the staffing hours form on each shift.
Missing Facility Name on Daily Staffing Sheets
Penalty
Summary
The facility failed to ensure nurse staffing information was accurate and posted daily for each shift. During review of the daily staffing sheets on 6/23/26 at 3:47 PM, the surveyor observed that the facility's name was missing from all of the daily staffing sheets. At 4:10 PM, the Chief Clinical Officer stated that the facility name should have been on the daily staffing sheets and was not.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to post accurate nurse staffing information at the nursing stations for 6/17/2026 through 6/24/2026, as required by its policy titled Posting Direct Care Daily Staffing Numbers. A review of the Nursing Staffing Daily Posting showed that the document did not list the actual time worked per shift for each category and type of nursing staff, including RN, LVN, and CNA; instead, it showed a combined total number of all nursing staff per shift. During a concurrent interview and record review on 6/24/2026 at 8:55 AM, the DON confirmed that the posting reflected combined total nursing staff per shift rather than the required breakdown by category and type. The DON stated the posting was inaccurate and should show the actual hours worked per shift, along with the type and category of nursing staff, because those details determine what kind of nursing care is provided to residents. During a later interview on 6/24/2026 at 9:00 AM, the DON stated the daily nursing postings are intended to inform residents, responsible parties, and visitors about the type, category, and hours of nursing care provided per shift, and that the postings must be accurate to prevent misinformation and confusion.
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