Sufficient Nursing Staff
A complete F-725 §483.35(a)(1)–(4) sufficient nursing staff policy plus survey-ready documentation tools for skilled nursing facilities. This template is built to be inserted verbatim into the facility's nursing P&P binder or adapted to site-specific language. It covers the facility-wide staffing assessment, the nurse-hours-per-resident-day calculation, the staffing pattern by shift, the registered-nurse coverage requirement, the licensed-nurse coverage requirement, the registered-nurse food-and-drug administration function exemption documentation, and the surveyor-encounter workflow CMS uses during F-725 investigations.
F-725 is the F-tag most commonly missed because facilities assume they meet it by completing the CMS-671 staffing form and the CMS-672 staffing summary form. They don't. The regulation is a multi-part requirement: the facility must (a) have sufficient nursing staff of all levels to provide nursing and related services that attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; (b) except when waived under §483.35(b), provide a registered nurse on the day tour 8 hours a day, 7 days a week; (c) except when waived, provide a registered nurse on the evening and night tours (the "RN on each tour" requirement applies to facilities paid under the non-waiver provision); (d) designate a registered nurse to serve as the director of nursing on a full-time basis; and (e) maintain sufficient licensed and unlicensed nursing staff to meet the facility's assessed resident acuity. Each of these is an independent citation trigger and surveyors cite each part independently when the documentation breaks down.
The most common citation patterns surveyors consistently document include: CMS-671 / CMS-672 forms with calculations that don't match the facility's actual posted schedule; resident acuity assessment not updated when census or acuity shifted; posted schedule not matching the actually-worked schedule for the trailing 30 days; recurring use of agency staff at levels that exceed facility-defined thresholds without an assessment of the workflow impact; lapses in registered-nurse coverage outside of any granted waiver window; and absence of the RN documentation tie to food-and-drug administration when the facility invokes the §483.35(a)(4)(B) exemption. This template gives the DON, the administrator, the staffing coordinator, and the unit nurse manager a single shared paper trail so that the staffing assessment, the staffing plan, the actually-worked schedule, and the waiver/documentation chain all survive the F-725 chart review.
CMS guidance (State Operations Manual Appendix PP, F-725) ties the staffing assessment to the facility's actual resident population at the time of assessment. Generic staffing matrices that don't reflect the assessed acuity are treated as presumptive failures of the assessment requirement. The CMS Staffing Rating system (PBJ-derived) is informational to the surveyor but is not a substitute for the facility's own documentation of sufficient staffing. Surveyors pull MDSC, MDS-derived acuity data, facility-reported PBJ data, the actual posted and worked schedule for the trailing 30 days, complaint and incident patterns that implicate staffing, and family/staff interview evidence when investigating F-725.
This template is intended for use by the administrator, the DON (who is typically the designated director of nursing on a full-time basis), the staffing coordinator, the unit nurse manager, the Staff Development Coordinator, and the PBJ coordinator. Facility leadership shall review the staffing assessment at minimum quarterly and any time the facility experiences a measurable change in resident census, acuity, or service delivery (extended leave, significant new admission cohort, policy-driven resident recommendation of discharge). The included surveyor-encounter sheet shall be walked at minimum 30 days before any anticipated survey window.
Purpose
The purpose of this policy is to establish a single, defensible, surveyor-reviewable staffing program under 42 CFR §483.35(a)(1)–(4). It defines the population assessment framework, the staffing matrix methodology, the posting and worked-schedule reconciliation, the registered-nurse coverage requirement with the §483.35(a)(4)(B) food-and-drug-exemption documentation where appropriate, the recurring-readjustment protocol when acuity changes, and the documentation chain required to demonstrate that the facility maintained sufficient nursing staff of all levels to meet resident needs throughout the review window.
Policy
The facility shall maintain sufficient nursing staff of all levels to provide nursing and related services that attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility shall maintain documented evidence of a facility-wide staffing assessment that reflects the current resident population, acuity, and service-delivery requirements. The facility shall, except when a §483.35(b) waiver has been granted for the relevant period, ensure that a registered nurse is on duty on the day tour 8 hours a day, 7 days a week. The facility shall designate a registered nurse to serve as the director of nursing on a full-time basis. The facility shall maintain sufficient licensed and unlicensed nursing staff to deliver the assessed care plan of each resident, and shall document adjustments to staffing when acuity or census changes. The facility shall reconcile posted and actually-worked schedules for the trailing 30 days, and shall document any variation with clinical justification. All documentation generated by this program shall be retained for the trailing 12 months and shall be retrievable within surveyor timeframes.
Scope
This policy applies to all nursing staff (registered nurses, licensed practical nurses, certified nursing assistants, restorative nursing aides, medication aides where permitted by state scope) providing direct or indirect nursing services in the facility. It applies to the director of nursing, the staffing coordinator, the unit nurse manager, the administrator with respect to scheduling and budget authority, and the Staff Development Coordinator with respect to competency assurance. The policy applies during routine operations, when census or acuity changes, when extended leave or agency-staff supplementation is required, and when any of the §483.35(b) waiver provisions are in effect in the relevant period. It does not replace individual state-specific nurse-to-patient ratio rules where those rules are more stringent than the federal floor.
Procedure
Facility-wide staffing assessment
The administrator and the DON shall jointly conduct a documented facility-wide staffing assessment at minimum quarterly. Assessment inputs shall include: current resident census and acuity, average daily hours per resident per nursing level, current PBJ-reported hours per resident per day, recent incident patterns and the staffing context for those incidents, family and resident council feedback, any recent state-survey citations related to service delivery, and any recent deficiency citations. The assessment shall identify any staffing gap, shall document the corrective action plan, and shall be retained in the survey binder.
Nurse-hours-per-resident-day calculation
The staffing coordinator shall maintain a current calculation of nurse-hours-per-resident-day (HPRD) by nursing level and by shift, using a methodology that reflects the facility's actual schedule. The calculation shall be updated at minimum monthly and shall be reconciled with the CMS-672 facility staffing summary form. The methodology shall explicitly identify: total resident census used, total productive nursing hours by level by shift (excluding non-productive time such as paid breaks without resident care responsibility), and the resulting HPRD. The facility shall maintain documentation of any HPRD values below the facility-defined target and the documented corrective action.
Posted and worked schedule reconciliation
The facility shall post a daily nurse staffing summary per §483.35(g). The posted schedule shall be retained. The actually-worked schedule (with call-outs, late-arrivals, overtime, agency use, and shift swaps documented) shall be reconciled to the posted schedule at minimum monthly by the staffing coordinator. Any variation shall be documented with the date, the variation, the clinical justification, and the corrective action. Recurring variation patterns shall trigger a staffing-assessment revision.
Registered-nurse coverage
The facility shall ensure that a registered nurse is on duty on the day tour 8 hours a day, 7 days a week unless a §483.35(b) waiver has been granted for the relevant period. When a waiver is in effect, the documentation of the waiver status shall be maintained and shall be retrievable on surveyor request. When the waiver is not in effect and a registered-nurse day-tour gap occurs, the rationale (e.g., emergency staffing failure with documented escalation steps and same-day correction) shall be documented contemporaneously.
Director of nursing designation
The facility shall designate a registered nurse to serve as the director of nursing on a full-time basis. The designation shall be documented in the DON's job description, the facility's organizational chart, and the CMS-671 form. Any planned DON absence of more than 30 calendar days shall be covered by a designated interim DON whose qualifications are documented. The interim designation shall be communicated to the State Agency per state-specific requirements.
Sufficient licensed and unlicensed coverage
Beyond the registered-nurse coverage requirement, the facility shall ensure that licensed and unlicensed nursing staff are sufficient in number to deliver the assessed care plan. Sufficiency shall be measured against current resident acuity, current incident patterns, and current quality indicators, and shall be adjusted in real time when factors warrant.
Food-and-drug-administration exemption (§483.35(a)(4)(B))
When the facility invokes the §483.35(a)(4)(B) exemption allowing a non-RN to administer medications to residents whose condition has been stable, the facility shall maintain the documentation required by the regulation: a licensed nursing assessment of each affected resident, an identification of the staff member administering under the exemption, and a record of the medications administered. The exemption shall be invoked only as permitted by state scope-of-practice rules and only when the regulation's conditions are met.
Documentation
Documentation generated by this program shall include: quarterly facility-wide staffing assessments, HPRD calculations with methodology documentation, the facility's posted daily nurse staffing summary (retained per §483.35(g)), actually-worked schedule records, reconciliation notes, signed skilled nursing facility staffing summary forms (CMS-671, CMS-672) as submitted, director-of-nursing designation documentation, RN-on-documentation chain for waiver-period coverage where applicable, agency-staff usage logs, and the care-plan link for any resident whose staffing is invoked in survey context. Documentation shall be retrievable within surveyor timeframes and shall survive multi-day review windows.
Staff checklist
Administrator: ensure posted schedule is current and reconciled; ensure DON-designation documentation is current; ensure quarterly staffing assessment is completed with the DON. DON: lead the facility-wide staffing assessment; review recurring-incident staffing context monthly; approve any DON-interim designation; ensure regulatory RN coverage is documented. Staffing coordinator: maintain posted and worked-schedule reconciliation; maintain CMS-671/CMS-672 submission records; maintain agency-staff usage logs; escalate recurring variation patterns. Unit nurse manager: ensure adequate skill mix for current unit census and acuity; report any shift-level shortfall with corrective action; ensure shift-handoff communication includes staffing context. Staff Development Coordinator: ensure competency records for all nursing staff are current; ensure agency-staff competency verification is documented before shift start.
Surveyor-encounter sheet
When the surveyor requests F-725 documentation, the facility shall produce, in order: (1) the quarterly facility-wide staffing assessment for the most recent completed quarter and the trailing 12 months; (2) the HPRD calculation with methodology documentation for the trailing 90 days; (3) the posted daily nurse staffing summary records per §483.35(g) for the trailing 30 days; (4) the actually-worked schedule and reconciliation notes for the trailing 30 days; (5) the CMS-671 and CMS-672 forms as submitted for the trailing 12 months; (6) the current and historical director-of-nursing designation documentation; (7) waiver-period coverage documentation if any portion of the review window is within a §483.35(b) waiver; (8) agency-staff usage logs and competency verification for the trailing 30 days; (9) incident and complaint records that the surveyor pulls for the staffing-context review. The facility shall produce this documentation set within surveyor timeframes.
Survey prep checklist
30 days before any anticipated survey window, the administrator and the DON shall complete a pre-survey F-725 audit covering: quarterly staffing assessment currency (all four trailing quarters complete and retrievable); HPRD methodology documentation current; CMS-671 and CMS-672 forms current and accurate; posted and worked schedule reconciliation currency for trailing 30 days (≥ 90% reconciled); RN coverage documentation currency for trailing 30 days; DON-designation documentation current; waiver-status documentation current where applicable; agency-staff competency verification current; any documented staffing-context for incidents in the trailing 60 days. Documented corrective action shall be retained in the survey binder for any gap identified.
References
Primary regulatory authority: 42 CFR §483.35(a)(1)–(4) and §483.35(b)–(g) — Nursing Services. CMS State Operations Manual, Appendix PP — Guidance to Surveyors for Long Term Care Facilities, F-725. CMS Payroll-Based Journal (PBJ) staffing data reporting requirements and operational policy. CMS Long-Term Care Facility Staffing Payroll-Based Journal (PBJ) Policy Manual. CMS Staffing Rating methodology. State-specific nurse practice acts and state-specific nurse-to-patient ratio rules. Facility organizational chart and DON job description. CMS-671 and CMS-672 submission records.