Inaccurate Staffing Records and Incomplete Record Maintenance
Summary
The facility failed to ensure the accuracy and currency of the Daily Staffing Posting information, which had the potential to affect all residents. During a review on March 25, 2024, it was found that nursing administrative staff hours were incorrectly included in the Nursing Direct Care hours on several dates. The Corporate Administrator acknowledged that the facility was using administrative staffing hours as direct care hours, based on the misunderstanding that staff helping out with others throughout the day could be counted as direct care. This misunderstanding was clarified during the review of the Centers for Medicare & Medicaid Services policy manual, which specifies that hours should be reported based on the employee's primary role. Additionally, the facility did not maintain the Daily Nurse Staffing Posting Forms for the required minimum of 18 months. It was discovered that the forms did not accurately reflect staff absences due to call-outs and illness, as required by regulatory guidance. The Corporate Administrator admitted that the staff responsible for posting the forms was unaware of the requirement to keep the original forms for 18 months, resulting in the loss of these records. This oversight in maintaining accurate and complete staffing records was acknowledged by the facility's administration.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Incomplete Daily Staffing Posting: The facility failed to ensure the daily staffing posting included all required information. The posting showed the date and the total number of licensed staff with their designation, but it did not include the facility name, a clearly identified census, or the total actual hours worked by licensed staff. The senior manager of scheduling operations, RN-A, the DON, and the administrator gave differing accounts of who was responsible for updating weekend changes and acknowledged uncertainty about the exact posting requirements.
Daily staffing postings on all three units showed staff names and disciplines, but the hours scheduled and current census were not visible. The DON confirmed the census was not included, and the administrator verified that the hours on the back of the posting reflected the prior day's schedule because the new posting had been placed on top of it.
Daily nurse staffing postings were not properly displayed in a prominent location and did not include the facility name or the actual total number and actual nursing hours worked. The posting was only on a bulletin board that could be missed from part of the lobby, and staff reported the form showed scheduled rather than actual staffing information; one observation also showed the prior day's posting instead of the current day.
The facility did not consistently post complete daily nurse staffing information as required, omitting elements such as the facility name, current date, resident census, and the breakdown of staff hours by category (RN, LPN, CNA) on multiple days. Observations showed that the staffing postings were incomplete, and the DON confirmed that the postings were required to include all of these elements and that they did not. This failure had the potential to affect all residents by limiting access to accurate information about the staff available to meet their needs.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility did not maintain the required 18 months of posted nurse staffing records. Surveyors observed that only the current day’s staffing information was posted in the lobby, and during interviews the new DON reported uncertainty about whether historical staffing records were kept. The Administrator later stated that the facility was trying, but unable, to access prior posted staffing information. As a result, residents and the public could not review the required historical nurse staffing data.
Incomplete Daily Staffing Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting included all required information. Review of the staff schedule and facility staff posting documentation dated 4/13/26 through 5/13/26 showed that the posting included the date and the total number of licensed staff with their designation, but it did not include the facility name, the census number clearly identified as such, or the total number of actual hours worked by licensed staff. On 5/13/26, the senior manager of scheduling operations stated they were responsible for updating and posting the daily facility staffing information Monday through Thursday evenings and posting the whole weekend on Friday night, with weekend nurses responsible for updating any changes. The senior manager stated they were unsure of the exact requirements for the posting. That same day, RN-A stated weekend staffing changes would be emailed to the DON and scheduling team and updated on internal unit sheets, but RN-A was unaware of responsibility to update the daily facility posting. The DON stated they were unsure whether weekend updates were always being done and confirmed the charge nurse was responsible for weekend changes. The administrator confirmed the scheduling team was responsible for updating and posting the daily staffing information and stated the posting needed to include the census and how many nurses and nursing assistants were in the building each day.
Daily Staffing Posting Missing Census and Visible Hours
Penalty
Summary
The facility failed to ensure that the daily nurse staffing posting included the current census and visible hours worked. During observations on 5/4/26, 5/5/26, and 5/6/26, staffing sheets were posted on all three floors, and the facility name, staff names, and disciplines were visible, but the hours scheduled and current census were not visible. During an interview on 5/7/26 at 12:04 p.m., the DON stated the scheduler posted the daily staffing on all three units and confirmed the current census was not included in the posting. During an interview on 5/5/26 at 6:04 p.m., the administrator showed the staffing schedule posted on the first floor in an acrylic stand behind a plexiglass window; the front page visible through the plexiglass showed staff names and titles sorted by shift, but hours worked were not visible. The administrator then spun the posting around and confirmed the total hours listed on the back reflected 5/4/26 rather than 5/5/26 because the 5/5/26 posting had been placed on top of the prior day's posting. The administrator also stated the census was not printed on the daily staffing sheets, but it could be.
Daily Nurse Staffing Posting Not Properly Displayed
Penalty
Summary
The facility failed to post the daily nurse staffing data in a prominent place that included the facility name and the total number and actual hours worked for nursing staff for 5 of 5 observed days during the survey period. On 05/03/2026 at 9:00 AM, the front entrance, receptionist desk, and lobby areas had no daily nurse staffing data posted. On 05/04/2026 at 11:00 AM, 05/05/2026 at 6:16 AM, 05/06/2026 at 8:55 AM, and 03/07/2026 at 8:51 AM, the staffing postings were located on a glass-covered bulletin board to the left of a wall picture and grandfather clock after entering the front entrance and turning left toward the 100/200 halls, and could be missed by someone turning right toward the 300 hall. The postings reviewed did not include the facility's name and did not show actual total number or actual nursing staff hours; instead, the form showed "Actual Scheduled Staff" and "Actual Scheduled Hours." On 05/05/2026 at 6:16 AM, the posting displayed staffing information for the previous day, while a later observation at 8:03 AM showed the correct date posted. During interview, the Staffing Coordinator stated the bulletin board was the only location for postings, did not know why the form lacked the facility name, and said the form had been that way since February 2026. The Administrator stated the nurse staffing postings were posted the day before for the next day and typically revised within 24 hours as needed, but could not explain why the form did not have the facility's name or why actuals were not posted.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a manner that informed residents, visitors, and resident representatives of the staff available to meet resident needs. The State Operations Manual (SOM), Appendix PP, requires that facilities post daily, in a location readily accessible to residents and the public, the facility name, current date, total number of hours worked by each staff category per shift (RN, LPN, CNA), and the resident census. On multiple observed dates and times (4/26/26, 4/27/26, and 4/28/26), the posted staffing information did not include all of these required elements, specifically omitting the facility name, current date, census, and the breakdown of licensed and unlicensed staff by category (RN, LPN, CNA). During an interview on 4/29/26 at 5:33 PM, the DON acknowledged that the posting is required to include the facility name, current date, census, and the number of licensed and unlicensed staff by category and confirmed that the posting did not contain all required elements. This failure had the potential to affect all residents who receive services in the facility by limiting access to accurate staffing information, as the incomplete postings did not fully reflect the staff available to meet resident needs as required by regulation.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Failure to Maintain 18 Months of Posted Nurse Staffing Records
Penalty
Summary
The facility failed to retain 18 months of records for the daily posted nurse staffing information, affecting all 89 residents as identified on the census list provided by the Administrator on 04/29/26. During an observation of the front lobby at 8:54 AM on 04/29/26, surveyors noted that the current day’s nursing staff information was posted. However, in a subsequent interview at 8:58 AM, the DON, who reported being new to the position, stated she was unsure whether the facility maintained 18 months of the posted nursing staff information. In a later interview on 04/30/26 at 12:47 PM, the Administrator stated that the facility was attempting to obtain access to the historical posted nursing staff information but had been unable to do so. Because the facility did not have 18 months of posted staffing records available, residents or the public would not have access to review the required historical nurse staffing information.
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