Incorrect Daily Nurse Staffing Census Postings: The facility failed to ensure the daily nurse staffing posting reflected the correct resident census on multiple reviewed days. Record review showed repeated mismatches between the posted census and the detailed census report, while interviews revealed the overnight nurse posted the information using the midnight census, the SW was unsure whether bed hold information was included, and the MRC had not been updating the census before the interview.
Failure to Post Current Nurse Staffing Information: Surveyors observed that the daily nurse staffing posting was outdated and still displayed the prior workday's information instead of the current day. The Staffing Coordinator said weekend postings were prepared in advance and left for the Manager on Duty or Nursing Supervisor to change, but the posting had not been updated when the survey team arrived. The Nurse Supervisor did not know who was responsible for updating the weekend posting, while the Administrator stated the posting should be changed daily in the morning.
Inaccurate Daily Nurse Staffing Sheets: The facility failed to keep daily nurse staffing sheets accurate and posted each day. Posted sheets were outdated or missing for some days, and several sheets failed to list an RN even though timecards showed an RN worked at least 8 consecutive hours. The Staff Scheduler said he did not include the Wound Care Nurse, an RN, when she was the only RN present, and sometimes prepared weekend sheets in advance and adjusted them later.
Inaccurate Daily Nurse Staffing Sheets: The facility failed to accurately post licensed nursing hours on daily staffing sheets reviewed across multiple shifts. The posted totals for RNs and LPNs did not match the actual scheduled hours, and the Staffing Coordinator stated she calculated hours by counting staff in the building and multiplying by 12 rather than using each nurse’s actual hours worked. The Administrator stated he expected the staffing sheet to accurately reflect current staffing.
The facility failed to post accurate daily nurse staffing data, with posted RN, LPN, and NA counts not matching the staffing schedule across multiple shifts. Record review showed repeated discrepancies in both licensed and non-licensed staffing totals, and interviews revealed the previous Scheduler had not been adjusting the postings when staffing changes occurred. The DON had only recently taken over scheduling after the previous Scheduler left, and the Administrator was unsure why the postings were not corrected.
Failure to Post Updated Daily Nurse Staffing Sheet: The facility did not post an updated daily nurse staffing sheet for residents and visitors on one surveyed day. The sheet near the main entrance remained dated from the prior Friday and did not reflect the current date, census, or staffing information. The Scheduler said weekend staff were responsible for updating and posting the sheet, while an RN supervisor reported she updated it but became busy with resident care and did not post it. The DON confirmed the sheet was not updated because the weekend supervisor became busy.
Inaccurate skilled unit census was posted on the nurse staffing sheets for multiple days. The Scheduler said she counted residents from both the skilled unit and LTC unit together and entered the same total for all shifts, rather than separating the census by unit. The DON stated the skilled unit and LTC census should be posted separately, and the Administrator said the process failed because the Scheduler had received inaccurate training.
Daily nurse staffing sheets were posted with a single Licensed Nursing Staff column that did not separately total RN and LPN hours or counts, affecting all 33 days reviewed. The Staffing Coordinator, Nurse Supervisor, DON, and Administrator each described the process used to complete and review the sheets, and both the Staffing Coordinator and Nurse Supervisor stated they were unaware that RNs and LPNs had to be totaled separately.
Surveyors found that the facility did not maintain and post a current daily nurse staffing sheet at the main entrance, as the sheet displayed was several days out of date and did not reflect the current census or staffing. The Scheduler reported preparing and handing off completed staffing sheets to the ADON, who placed them in a staffing binder at the nurse's station with the expectation that nursing staff would update and post them. The DON and Administrator confirmed that the charge nurse was responsible for ensuring the daily nurse staffing sheet was updated and visibly posted for residents and visitors on weekends, but this did not occur on one of the reviewed days.
The facility failed to accurately post daily nurse staffing information when reception staff, using schedules prepared from a master schedule, completed the public staffing report without understanding that some RNs, LPNs, and NAs were splitting shifts or working 12‑hour shifts. Receptionists counted each name on the schedule as a full staff member for the entire shift, did not receive updates on call‑outs or schedule changes, and did not revise the posted report once it was placed in the lobby. The Scheduler did not communicate staffing changes to reception, and the Administrator did not review the report for accuracy, resulting in repeated discrepancies between posted staffing levels and actual scheduled staffing across all three shifts on most days reviewed.
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