Incomplete and inaccurate daily staffing posting: Surveyors observed that the staffing board was outdated and the daily staffing log was incomplete, missing the census number and hours of service. An CNA was listed on the day shift assignment but was not on the hall, and an RN stated she was unaware the CNA had called in. A WC confirmed the daily staffing had not been posted and said the night shift was supposed to post it.
Failure to Post Daily Nurse Staffing Information: Surveyors observed that the facility did not post updated staffing forms showing the actual hours worked by RN, LPN, and CNA staff responsible for resident care. A staffing form was displayed at the front desk, but the prior day's form was not available, and there was no binder with previous forms for public access. The Admin, DON, and Admin Asst confirmed they were unaware the staffing forms had to be updated and posted.
Failure to post and retain daily nurse staffing data. Observations showed the staffing data was not posted, and the Interim Administrator confirmed it should have been posted daily. The Interim Administrator also could not locate the staffing postings going back to 08/27/2025, despite the requirement to retain them for at least 18 months.
Failure to Complete and Post Daily Nursing Census: The facility did not ensure the Daily Nursing Census form was completed and posted each day. Surveyors observed an outdated form posted near the front desk with no current daily entry, and review of prior forms showed multiple missing dates. Interviews revealed the RN, ADON, and DON each believed another staff member was responsible for weekday completion, and the DON confirmed the forms were not completed daily as required.
The facility failed to post complete daily nurse staffing information as required. Surveyors observed that Daily Nursing Staff Posting forms for consecutive days were displayed without documenting the resident census at the start of the shift, the daily nursing hours required, or the actual nursing hours worked. An RN responsible for staff development confirmed that these required data elements were not posted for those days and acknowledged that she had routinely posted the forms without the missing information.
Failure to post daily nurse staffing data: The facility did not post the nurse staffing information at the beginning of each shift in a prominent, readily accessible location. Observation showed the staffing data was not posted with the resident census, total number, or actual hours worked by licensed and unlicensed staff. The ADON stated the assignment sheets were kept inside the nurses' station and did not include the required details, and the Assistant Administrator confirmed the staffing pattern was not posted outside the nurses' station for residents, visitors, and staff to access.
Failure to post daily nurse staffing information: A Staff Reporting Form for licensed and unlicensed nursing staff directly responsible for resident care was not posted at the beginning of each shift. Observations showed an outdated form remained posted at the nurse's station while current forms were missing, and the ADON confirmed the required daily posting had not been done.
Nurse staffing information was not posted at the beginning of the shift in a clear, readable format accessible to residents and visitors. An observation of Hall W and the nurse's station did not show the staffing information, and the ADON/IP and ADM confirmed it was not posted even though it should have been.
A facility failed to keep the daily posted nurse staffing information accurate and current. Surveyors observed the posting remained dated several days earlier throughout the day, and S2HR stated she posts staffing information from the prior day rather than the current date and confirmed no staffing information was posted for the weekend dates.
Failure to post daily nurse staffing information. Facility observations found no staffing sheet posted in a prominent, readily accessible location for residents and visitors. The required posting did not include the facility name, date, census, or the total number and actual hours worked by staff responsible for resident care. An interview with the Benefits Coordinator confirmed she was responsible for calculating and posting the staffing hours and that it had not been done daily.
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