F0732

C

Failure to Properly Post Daily Direct Care Nurse Staffing Information

Houston, Texas Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to properly post daily direct care nurse staffing information as required by policy and regulation. On a specific survey date at 10:48 AM, surveyors observed that the clear placard designated for staffing information, located on the wall by the DON’s office between the 300 and 400 halls, was empty and no facility direct care staffing information was posted. The facility’s policy required that staffing information be posted within two hours of the beginning of each shift in a prominent location accessible to residents and visitors, and that 24 hours of staffing information be maintained in a single location.

During an interview, the Staffing Coordinator stated she had been responsible for calculating, updating, and posting the direct care staffing numbers daily for about one year. She explained that she usually updated the posting around 8 AM but was not aware of the required time frame for updating the posting per facility policy. She also acknowledged that the current posting location would not be visible to anyone going exclusively to the 100/200 and 300 halls, as it was only on the route to the 300 hall and on one side of the building. The Staffing Coordinator reported that when she arrived on the survey date, she assisted CNAs with resident transfers and therefore did not update the staffing posting until just before her interview with the surveyor.

Record review of the Direct Care Daily Staffing Numbers from the beginning of January through the day before the survey revealed that, although the forms listed the facility name, date, census, shift categories, and the number of each type of staff, the “Scheduled” and “Hours Worked” columns were consistently left blank. The Staffing Coordinator stated she had never documented the total hours worked for each direct care staff type since starting in her role, had not been trained to do so, and did not know that documenting total hours worked was required by facility policy or regulation. The facility’s written policy specified that the posted form must include the actual time worked during the shift for each category and type of nursing staff, and that the staffing coordinator must compute the number of direct care staff and complete the form within two hours of the beginning of each shift, with the shift supervisor recording the census and posting the information in the designated location.