Inaccurate Facility Assessment of Nursing Staffing Levels
Penalty
Summary
The facility failed to ensure that its Facility Assessment accurately reflected current staffing levels and needs, as required by its own policy and regulatory standards. The Facility Assessment, last updated in March 2025, documented the need for two Registered Nurse (RN) Supervisors on the 11:00 PM-7:00 AM shift and one RN on the first floor during the 7:00 AM-3:00 PM shift. However, review of staffing sheets and interviews with staff revealed that only one RN Supervisor was scheduled for the overnight shift, and the first floor was staffed with three Licensed Practical Nurses (LPNs) instead of an RN during the day shift. The staffing coordinator and Director of Nursing confirmed that the par level sheet, which determines minimum staffing, had been updated to reflect these changes, and that the RN position on the first floor had been replaced by an LPN about a month prior to the survey. Despite these changes, the Facility Assessment was not updated to reflect the current staffing model, leading to discrepancies between documented and actual staffing practices. The Administrator acknowledged that the numbers in the Facility Assessment were based on staffing from specific dates in March 2025 and did not represent daily or current needs. The failure to update the Facility Assessment as required resulted in inaccurate documentation of the resources necessary to provide competent care to residents during both routine operations and emergencies.