Failure to Post and Retain Required Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to consistently post and retain daily nurse staffing information as required by regulation and facility policy. Surveyors reviewing 18 months of records on 03/24/26 found that the facility lacked any posted staffing information from 08/01/25 through 11/14/25, as well as additional specific missing days in November and December 2025, January and February 2026, and March 2026. On 03/24/26 at 1:49 PM, observation showed that the daily posted staffing sheet on display was dated 03/23/26 instead of the current date. The facility’s written policy from October 2021 required that within two hours of the beginning of each shift, the numbers of licensed nurses and CNAs directly responsible for resident care be posted in a prominent, accessible location in a clear and readable format, and that records of staffing information for each shift be kept for at least 18 months or longer if required by state law. Interviews with staff clarified how the posting process was intended to work and revealed gaps in implementation. On 03/31/26, an LN stated that an administrative staff member was responsible for posting the daily staffing sheets during the week, and that on weekends the sheets were prefilled and posted by the charge nurse, who would adjust them if needed. An administrative nurse confirmed that the same administrative staff member was in charge of both posting and retaining the daily staffing information, and that on weekends the charge nurse was responsible for posting and updating the prefilled sheets. Another administrative staff member reported there had been a changeover in the staff responsible for maintaining the daily posted staffing sheets and acknowledged she had not been able to locate all of the required records from the past 18 months. At the time of the survey, the facility had a census of 54 residents and a sample of 12 residents, but the deficiency centered on the facility’s failure to post and retain required staffing information rather than on specific resident clinical issues.
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