The facility failed to ensure daily nurse staffing postings were accurate and complete. Surveyors observed multiple posted staffing sheets that did not include total hours worked and, at one point, did not list the facility name. Review of additional dates showed the same omission of total hours worked. An administrative nurse reported that a night-shift nurse completed and posted the next day’s staffing sheet and indicated that a column labeled "actual hours" was intended to represent total hours worked, despite the facility’s written policy requiring clear computation and recording of staffing levels and census information on the Daily Nurse Staffing form.
Surveyors found that daily nurse staffing information was not consistently posted or retained as required. Over an 18‑month review period, multiple days of staffing records were missing, and the sheet displayed during observation was not for the current date. Staff interviews showed that an administrative staff member was responsible for weekday postings and record retention, while charge nurses were expected to post and update prefilled sheets on weekends. A changeover in the personnel responsible for maintaining these records contributed to the inability to locate all required historical staffing sheets, despite a written policy requiring timely posting and 18‑month retention of nurse and CNA staffing data.
The facility did not ensure that daily nurse staffing sheets accurately reflected actual hours worked by RNs, LPNs, and CNAs. On the day reviewed, the posted staffing form, observed twice near the nurse’s station with a census of 40 residents, lacked actual hours worked per shift for licensed and unlicensed staff providing resident care. An LN and administrative nurses reported that nurses did not update the posted sheet when staff were late or absent and that the business office added actual hours at the end of the week, contrary to facility policy requiring real-time updates after each shift.
The facility did not follow its policy requiring daily posting of nurse staffing information for each shift. Surveyors observed that three houses lacked accurate or current staffing sheets, with the last posted date more than a month old, despite an active resident census. An administrative staff member confirmed that staffing sheets were expected to be completed and posted daily for all licensed and unlicensed staff directly responsible for resident care.
The facility failed to follow its policy for posting daily nurse staffing information by not including the actual hours worked by nursing staff on the publicly posted staffing sheets. On multiple observed occasions and in prior records, the sheets lacked required details about actual time worked for each category and type of nursing staff, despite the facility’s policy specifying that this information, along with census and staffing categories, must be recorded and posted. Administrative staff and a CMA responsible for staffing confirmed that the posted sheets did not contain the actual hours worked.
The facility failed to ensure the daily staff posting included the actual hours worked by nursing staff. An observation found the staff posting lacked actual hours worked, and review of multiple daily postings showed the same omission. Administrative Staff B stated she had never been educated to post actual hours worked, while Administrative Staff C said she expected the actual hours to be posted. The facility did not provide a policy for posted nursing staff.
Incomplete Daily Nurse Staffing Postings: The facility failed to ensure the daily nurse staffing sheets posted near the nurse's station included actual hours worked for licensed and unlicensed staff. The posted forms lacked actual hours on multiple days, and review of prior staffing sheets showed several months with missing or incomplete postings. An Administrative Nurse stated the charge nurse completed the sheet without actual hours and the business office filled it in later, while another Administrative Nurse said she was unaware actual hours had to be posted.
Nurse Staffing Information Not Posted: The facility failed to post daily nurse staffing numbers and actual hours worked during the survey, and staffing sheets were not available after September 2025. Observations showed the required staffing information was missing, and an admin staff member stated the facility had switched to timesheets, had only started posting staffing sheets the day prior, and did not know where the earlier sheets were. The facility policy required the Nurse Staffing Sheet to be posted at the beginning of each shift and maintained for at least 18 months.
Posted nurse staffing sheets were missing required actual hours worked information. Observations showed the sheets lacked this data on multiple occasions, and record review confirmed the same issue on prior staffing sheets. An Administrative Nurse stated the posted sheet should include an accurate census, total staff per shift, and actual and total hours worked, consistent with facility policy.
The facility failed to post complete nurse staffing information for the census of 47 residents because the daily staffing sheets did not include the actual hours worked by nursing staff. Review of the staffing sheets showed the required hours were left blank, and an Administrative Nurse confirmed the omission. The facility policy stated the nurse staffing sheet must be posted daily and include the total number and actual hours worked by nursing staff.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.