Failure to Maintain and Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was properly posted and maintained as required by federal regulations. During an observation, the Administrator indicated that the nurse staffing document was posted near the facility entry, but upon review, the posted document contained an incorrect day of the week. The Administrator acknowledged the error and stated that the staff member responsible would correct it. When asked to review the prior year's posted staffing records, the Administrator provided a binder containing the documents, which were used to track the number of RNs, LPNs, and CNAs on each shift, their hours worked, the date, and the resident census. Upon further review of the binder, it was discovered that approximately 60 days of posted staffing sheets were missing for the period from October 2024 to April 2025. The Administrator confirmed that the staff member previously responsible for completing the daily posted staffing documents was no longer in that role. As a result, the facility did not have the required nurse staffing information available for multiple days, preventing residents and visitors from knowing which clinical staff were working on those days.
Plan Of Correction
Element 1: Posted Nurse Staffing document was updated with the corrected day of the week during survey. Element 2: Audit completed of Nurse Staffing binder to identify any missing postings. Element 3: Education completed with Staffing Coordinator to assure daily Nurse Staffing postings are completed accurately and available for review. The Administrator/Designee will verify daily, Monday through Friday, that Nurse Staffing is posted accurately. Weekend receptionist will verify, Saturday and Sunday, that Nurse Staffing is posted accurately and immediately notify the Administrator if not posted. Element 4: Administrator/Designee will complete random weekly audits, four weeks, of Nurse staffing posting to assure the document is posted accurately, with findings submitted to QAPI for review and recommendations. Element 5: Staffing Coordinator is responsible for maintaining compliance.