Inaccurate Daily Nurse Staffing and Census Posting
Summary
The deficiency involves the facility’s failure to ensure that the Daily Staff Posting accurately reflected the actual number and type of direct care nursing staff on duty and the current resident census. Surveyors reviewed PBJ staffing data, Daily Staff Postings, signed staffing/assignment sheets, and time clock punch details for multiple weekend dates and found repeated discrepancies. On several reviewed dates, the number of CNAs, LPNs, RNs, CMAs, and valets listed on the Daily Staff Posting did not match the actual staff who worked, and the total hours posted did not match the hours recorded in the punch details. The facility’s own assessment indicated a licensed capacity of 112 residents, an average daily census of 90, and a staffing plan specifying numbers of nurses/CMAs and direct care staff per shift, but the posted staffing information did not consistently align with actual staffing. On June 30, 2024, the Daily Staff Posting showed 5 CNAs and 60 CNA hours for the night shift, while the signed staffing sheet and punch details showed only 4 CNAs worked, with 50.23 actual hours after one CNA called off. On September 21, 2024, the posting showed no valets on the day shift, one RN and two LPNs on the night shift, and 5 CNAs on the night shift, but punch details showed 2 valets worked part of the day shift, no RN worked the night shift, 3 LPNs worked the night shift for 37.74 hours, and only 4 CNAs worked the night shift for 49.49 hours. On December 29, 2024, the posting showed 2 LPNs and 24 LPN hours on the day shift and 5 CNAs and 60 CNA hours on the night shift, but the assignment sheet showed one LPN called off and an RN erroneously listed as an LPN, and one CNA called off for the night shift; punch details confirmed only 1 LPN worked 12.40 hours on days and 4 CNAs worked 41 hours on nights. On March 8, 2025, the posting listed 9 CNAs and 108 CNA hours and 5 valets and 60 valet hours on the day shift, and 6 CNAs and 72 CNA hours on the night shift, but the assignment sheet showed only 7 CNAs scheduled for days with one CNA calling off on days and one CNA calling off on nights. Punch details showed 8 CNAs actually worked 95.39 hours on days, 4 valets worked 42.61 hours on days, one CNA scheduled for nights worked days instead, and only 4 CNAs worked 48.76 hours on nights. On May 4, 2025, the posting showed 24 CMA hours and 9 CNAs with 108 CNA hours on the day shift, but the assignment sheet documented 2 CNAs called off; punch details showed 22.80 CMA hours and 8 CNAs working 91.86 hours. During the survey entrance, the Daily Staff Posting at the reception desk lacked the census, the charge nurse could not state the current census, and the ED initially gave an incorrect census that differed from the CMS-671 form before later confirming the correct number. On the following day, the Daily Staff Posting again lacked the census until it was later updated. Interviews with the staffing coordinator, HR, and DON confirmed that the Daily Staff Posting is intended to show how many staff are working and the census, and they acknowledged that accurate posting is important for compliance and for informing the public, but the postings reviewed were not accurate or consistently completed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Nurse staffing posting missing resident census. The nurse staff posting observed by the DON office listed nursing hours by shift and discipline, but the census section was blank. The DON confirmed the census should have been included, and facility policy required the resident census at the beginning of the shift to be posted with the staffing information.
Inaccurate daily staffing posting. The facility failed to keep the staffing sheet current and accurate for 2 of 6 days. On one morning, the posting was still dated from the prior Friday, and the Staffing Coordinator said weekend postings were left as blank copies at the reception desk and she was unsure whether receptionists knew how to complete them. She also stated that when an LPN called out, she did not update the posting to show that 2 licensed nurses actually worked the night shift, even though the census was 75.
Failure to Post Daily Nurse Staffing and Census Information: The facility did not post the required daily staffing and census document during facility tours, and the required RN, LPN/LVN, CNA, and census information was not posted at the beginning of each shift. The DON said the task had not been reassigned after the scheduler role changed, and the ADMIN said the posting duty had been missed for the prior two days despite the facility policy requiring the information to be posted within 2 hours of each shift start.
The facility failed to ensure daily nursing staffing postings were accurately completed and posted. Review of staffing sheets showed multiple blank shifts across several months and several dates with no RN identified, including shifts worked by agency nurses. The DON stated charge nurses were responsible for completing the form each shift, but she did not monitor the process, and staff interviews showed inconsistent understanding of who completed the posting.
The facility failed to ensure nurse staffing information was accurate and posted daily for each shift. During review of the daily staffing sheets, the surveyor found the facility name was missing from all of the staffing sheets, and the CCO confirmed it should have been included.
Inaccurate Daily Nurse Staffing Postings: The facility failed to post accurate nurse staffing information at the nursing stations, showing only a combined total of nursing staff per shift instead of the required breakdown of actual hours worked by RN, LVN, and CNA. The DON confirmed the postings were inaccurate and stated the information is intended to inform residents, responsible parties, and visitors about the type, category, and hours of nursing care provided.
Nurse Staffing Posting Missing Resident Census
Penalty
Summary
The facility failed to include the resident census on the nurse staff posting. During an observation on 7/20/26 at 3:46 p.m., the nurse staff posting dated 7/20/26 was observed on a bulletin board by the DON office and showed the total number of nursing staff hours broken down by day, evening, and overnight shifts, with spaces for RN, LPN, TMA, and NA, but the census area was blank. During an interview on 7/20/26 at 4:00 p.m., the DON stated that the night shift was responsible for posting the nurse staff posting and verified that the census area should have been included. The DON also stated that it is important to list the census and staffing so the information is available to residents and visitors. Facility policy titled Posting Direct Care Daily Staffing, dated 9/27/22, required the form to include the facility name, the date, and the resident census at the beginning of the shift, but the direct care daily staffing posting lacked the census information.
Inaccurate Daily Staffing Posting
Penalty
Summary
The facility failed to ensure daily staffing information was accurate and current for 2 of 6 days. Upon surveyor entrance on Monday morning, the staffing posting was still dated Friday and had not been updated before the night shift. During interview, the Staffing Coordinator stated that she posts the staffing sheet every morning Monday through Friday, but on weekends she leaves blank copies at the reception desk and was not sure whether receptionists know how to complete them. She agreed that the Monday morning posting was dated Friday. The Staffing Coordinator also stated that on Friday she had a nurse call out and did not update the staffing posting before the shift to reflect that 2 licensed nurses actually worked the night shift, even though the census was 75 and only one licensed nurse was listed on the posting.
Failure to Post Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to post daily nurse staffing information that included the facility name, current date, total number and actual hours worked by RNs, LPNs/LVNs, CNAs directly responsible for resident care per shift, and the resident census for 2 of 2 days reviewed. During observations on 06/30/2026 at 10:49 a.m. and 12:27 p.m., and again on 07/01/2026 at 09:50 a.m. and 12:50 p.m., surveyors did not observe a document with the daily census and nurse staffing information during facility tours. The report states the required current nurse staffing and census information was not posted at the beginning of each shift on those dates. During interview on 07/01/2026, the DON stated the document should be posted and that she had to verify the task was not overlooked. She said the scheduler position had recently changed to an as-needed, primarily remote role and the task had not been reassigned after that change. The ADMIN stated the document was typically posted after the morning meeting, that the prior Staffing Coordinator had been responsible, and that the task was reassigned to him after the position became empty; he stated the task seemed to have been missed for the prior two days. Record review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, dated revised August 2022, stated the facility will post nurse staffing data daily and, within 2 hours of the beginning of each shift, post the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care in a prominent location.
Incomplete Nursing Staffing Postings
Penalty
Summary
The facility failed to ensure required and accurate nursing staffing information was posted each day. During observation, the daily nursing staffing posting at the nurses station included the required categories for RN, LPN, TMA, and CNA, but review of postings for April through June showed multiple blank shifts and missing RN documentation. In April, 16 shifts were left blank, all on night shift, and an RN was not identified on five dates. In May, 12 shifts were left blank, including 16 night shifts and one evening shift, and on one date an RN in training was listed without another RN identified. In June, 16 shifts were left blank, including night, evening, and day shifts, and an RN was not identified on four dates. The DON stated charge nurses were responsible for completing the staffing posting at the start of each shift and that at least one RN was scheduled for eight consecutive hours every day, with a nurse leader scheduled on day shift Monday through Friday. The DON said the missing RN entries were primarily on shifts worked by agency nurses who likely did not know they needed to complete the form, and stated she did not monitor the process to ensure the form was completed each shift and each day. RN-A stated she had never filled out a staffing posting for a shift she worked, while LPN-A stated the charge nurse completed the posting using the electronic schedule and updated it for call-ins. The facility policy stated the charge nurse was to obtain and complete the staffing hours form on each shift.
Missing Facility Name on Daily Staffing Sheets
Penalty
Summary
The facility failed to ensure nurse staffing information was accurate and posted daily for each shift. During review of the daily staffing sheets on 6/23/26 at 3:47 PM, the surveyor observed that the facility's name was missing from all of the daily staffing sheets. At 4:10 PM, the Chief Clinical Officer stated that the facility name should have been on the daily staffing sheets and was not.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to post accurate nurse staffing information at the nursing stations for 6/17/2026 through 6/24/2026, as required by its policy titled Posting Direct Care Daily Staffing Numbers. A review of the Nursing Staffing Daily Posting showed that the document did not list the actual time worked per shift for each category and type of nursing staff, including RN, LVN, and CNA; instead, it showed a combined total number of all nursing staff per shift. During a concurrent interview and record review on 6/24/2026 at 8:55 AM, the DON confirmed that the posting reflected combined total nursing staff per shift rather than the required breakdown by category and type. The DON stated the posting was inaccurate and should show the actual hours worked per shift, along with the type and category of nursing staff, because those details determine what kind of nursing care is provided to residents. During a later interview on 6/24/2026 at 9:00 AM, the DON stated the daily nursing postings are intended to inform residents, responsible parties, and visitors about the type, category, and hours of nursing care provided per shift, and that the postings must be accurate to prevent misinformation and confusion.
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