Staff failed to include the unit census on daily nurse staffing/assignment sheets, with 19 of 19 reviewed sheets missing this information. When a surveyor reviewed staffing records to determine which staff were working during an alleged abuse incident on one unit, the census was not documented for that shift or for multiple subsequent days across all three shifts. A scheduling manager reported not knowing who was responsible for completing the assignment sheets or that census data was required, and the DON stated they had not previously been told that the census needed to be included on the assignment sheets.
Staffing ratios and the RN in charge were not posted on the unit white boards used for staffing assignments. Surveyors observed incomplete census and staffing boards on the clinical units, including missing GNA and LPN resident assignment ratios and, at one point, no RN identified on the census board. An LPN stated the boards were to be updated during shift change, but later observations still found no staffing ratios posted on the third-floor unit.
Failure to post required staffing information was identified when the front desk staffing tray was empty and the nurses' station assignment board was blank. An LPN was unsure who the night shift supervisor was, stated the board had been wiped clean for a new assignment, and said there may not have been a nighttime supervisor. The acting DON confirmed the staffing should have been posted.
Incomplete daily nurse staffing information was posted on multiple resident care units. Surveyors observed that staffing boards on several units had no staffing ratios posted, were not filled out, or listed only LPNs and RNs without including GNAs. Follow-up observation showed the same issues remained on multiple units, and the DON was informed during the survey.
Failure to Post Daily Staffing Information: Surveyors observed that the Daily Staffing posting at the front desk was outdated and did not show current staffing levels. The most recent sheet displayed was several days old, and the receptionist stated that nursing was responsible for posting the information. No current staffing information was posted when the concern was identified and later discussed with the DON.
Failure to post complete daily staffing hours. Review of staffing sheets showed the facility did not document the actual hours worked by licensed and unlicensed nursing staff each shift, and the posted schedules lacked the required staffing totals. An LTC staffing scheduler stated they only entered HPPD and were not aware the daily posting had to include the facility name, date, census, and actual hours worked by staff providing resident care.
Incomplete nurse staffing postings were observed on both unit staffing boards. The boards showed the correct date, facility name, and census, but did not list the actual hours worked for nurses or nursing assistants. The DON was informed of the missing information and stated she was not aware of the requirement.
Incomplete staffing postings were observed for one unit. The daily staffing and assignment form did not include the facility name or total hours worked per shift, and a lobby posting showed staffing ratios but not the resident census. Record review also found missing nursing hours on multiple shifts for one of four units. The LNHA acknowledged that some posted staffing forms were incomplete and that the lobby report did not meet regulatory requirements for posting nursing staffing hours.
Failure to Post Nurse Staffing Ratio Information: Surveyors observed that nurse staffing ratio information was not posted on the staffing boards on Units 100, 200, and 300, and Unit 200 had no visible staffing board in the secured area. The DON stated the ratio was on a separate paper on Unit 100, but the document was not filled out, and the secured area board was only visible through a small window and difficult for residents to read.
Failure to Post Required Nursing Staffing Data: Surveyors found that the unit dry erase board displayed the date, census, day-shift GNA/nurse ratios, and assignments, but it did not include the facility name, the total number and actual hours worked by RNs, LPNs/LVNs, and CNAs per shift, or information for other shifts. The DON confirmed the missing information and stated that some staffing details were kept on a schedule in the nurse's station that was not visible to residents or visitors.
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 July 29, 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.