In Part 1 of CMSCG’s revised Ftag of the Week for F725 Sufficient Nurse Staffing, we reviewed some of the basic revisions in the newly revised Appendix PP State Operations Manual (SOM) which will be effective March 25, 2025. We’ll continue reviewing the Investigative Procedure because there are several concerns which could be identified by a survey team during offsite prep, which will result in the concerns being reviewed in different ways during survey.
As you are likely aware, the PBJ data is detailed and granular, so the report can provide specifics we mentioned in Part 1. The entire survey team has to review the information provided in this report prior to survey. If issues are identified with licensed nurse coverage 24/7, this will impact discussion during the Entrance Conference. The facility will be notified during the Entrance Conference of dates where there were staffing issues identified and that the facility will be cited under F725 unless it can provide evidence to the contrary of what’s in the PBJ report. The “evidence” can be timesheets, timecards or other payroll information, but schedules are not sufficient.
One particular area of concern is if a facility triggers for excessively low weekend staffing. The surveyor has to ask at least two non-nursing frontline staff (i.e., housekeeping, dietary, maintenance) “focused” questions about the weekend staffing. These include querying frontline staff if there are ever time when there aren’t enough staff to take care of residents on the weekends – as evidenced by residents asking for assistance for long periods of time without receiving it. Staff may also be asked if rooms are not cleaned/ left messy on weekends, or if residents are not assisted with getting out of bed due to insufficient staffing levels. The answers to these interviews can quite obviously help a surveyor build a case related to staffing concerns, and this is a common way that we are seeing citations at F725 written now – even without additional guidance.
Surveyors are then instructed to review the Facility Assessment to determine if the facility has assessed resident needs and determined the number of staff needed to meet those needs. Consider that the cherry on top to a thorough case for a citation.
What Else to be Aware of
During the Resident Council meeting during survey, residents will be asked if they receive the help they need without having to wait a long time. This isn’t a new question to the survey process, but its inclusion under this tag will make sure surveyors do their due diligence. When CMSCG is doing a mock survey, this is a routine query to Resident Council attendees – and unfortunately, the answer is not always good.

One other area to think about is those resident observations, which can become a serious problem on surveys for a number of reasons. The revised guidance to surveyors asks them to observe for and assess the following laundry list of potential concerns which could be linked to insufficient staffing. How would your building fare?
- Offensive odors
- Residents receiving timely assistance with toileting and/or eating
- Residents are still in bed and not dressed mid-morning
- Residents remain unkempt or unclean for extended periods
- Residents’ care activities are consistent with their personal preferences, rather than when it is convenient for staff
- Staff rushing when providing care for residents, such as neglecting to explain what they are doing when assisting the residents
- If call bells and alarms are responded to timely
- Residents are yelling out, crying and/or sitting in hallways or by the nurses’ station
- Residents are wandering unsupervised and at risk
- Residents show signs of sedation (indicative of potential use of unnecessary psychotropic meds) which could assist staff with monitoring and caring for residents
- Devices or practices in use which restrict a resident’s freedom of movement
- Delays in timely medication administration
- Staff demonstrate competency when providing care or services and in accordance with professional standards
That’s a lot to think about but provides a good guide to use in your own facility when doing rounds. Take a look around when you’re making your own observations using the above list and see how your facility would fare. It’ll give you some additional insight beyond the PBJ data you’re submitting as to what experience your residents may truly be having related to having their needs met.