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F0732
C

Inaccurate Daily Nurse Staffing Sheets

Hendersonville, North Carolina Survey Completed on 08-27-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that daily nurse staffing sheets accurately reflected the nursing staff who worked on four out of six days reviewed. Record review showed discrepancies between the posted staffing sheets and the actual time clock reports. On several occasions, the staffing sheets indicated that a Registered Nurse (RN) was present during the day shift, while the time clock reports revealed that only Licensed Practical Nurses (LPNs) were present and no RN had worked. On another occasion, the staffing sheet did not list an RN, but the time clock report showed that an RN had worked for three hours during the shift. Interviews with facility staff revealed inconsistencies in the process for completing and updating the daily nurse staffing sheets. The Assistant Director of Nursing (ADON) was responsible for updating the sheets during the week, while the weekend nursing supervisor was responsible on weekends. However, the Central Supply Manager reported that she sometimes completed the sheets in advance for the weekend, and the receptionist would post them, with nursing staff expected to update them as needed for call-outs or schedule changes. The Administrator confirmed these responsibilities and stated that the expectation was for the sheets to be updated to accurately reflect the staff who worked each shift.

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