F0732

E

Inaccurate Daily Nurse Staffing and Census Posting

Lakeside, Arizona Survey Completed on 11-19-2025

Penalty

No penalty information released

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.