Incomplete Posting of Actual Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing information included the total number and actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care. Additionally, the posted information did not include the actual Direct Care Services Hours Per Patient Day (DHPPD) and Certified Nursing Assistant (CNA) DHPPD, as required. Review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD) forms for the month of July 2025 revealed that while scheduled hours and scheduled DHPPD were documented, the actual total direct care service hours, actual total CNA direct care service hours, actual DHPPD, and actual CNA DHPPD were missing for the entire month. During interviews, the Director of Staff Development (DSD) confirmed that there was no automated system to populate the actual hours on the required form, and that she was responsible for manually entering this information at the end of each day. The DSD acknowledged that she did not have the opportunity to enter the actual staffing data for July 2025. The Administrator was also informed of these findings and acknowledged the deficiency. No information about specific residents or their conditions was provided in the report.