Failure to Post Actual Nursing Staff Hours on Daily Staffing Information
Penalty
Summary
Surveyors identified a deficiency in the facility’s posting of daily nurse staffing information for a census of 89 residents. Observation of the posted staffing information showed that for all three shifts (6:00 AM–2:00 PM, 2:00 PM–10:00 PM, and 10:00 PM–6:00 AM), the postings did not include the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. Record review of posted nurse staffing hours from 10/01/2025 through 01/07/2026 confirmed that during this entire period, the facility’s postings lacked documentation of actual hours worked for any of the three shifts. In written communication and interviews, the Administrator stated the facility did not have a policy on posted nurse staffing information and acknowledged responsibility for ensuring the information was posted. The Administrator explained that a new staffing person was now responsible for posting the hours and that it had been a group effort, but could not explain why the actual hours worked were not transferred to the staffing posting form or documented for the period reviewed. The Administrator acknowledged that without documenting actual hours worked, they would not know if expected hours were met. In a separate interview, the DON also could not explain why the actual hours were not included on the posted nurse staffing information and acknowledged that the actual hours were not documented.
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