Inadequate RN Staffing and DON Role Misuse
Summary
The facility failed to ensure that the Director of Nursing (DON) served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. This deficiency was identified during a review of the Nurse Staffing Reports and Payroll Based Journal (PBJ) Reports, which revealed that the DON worked as the only Registered Nurse (RN) on several days when the resident census exceeded 60. Specifically, on multiple occasions in May and June 2024, the facility had only one RN on duty during the day shift, despite having a census ranging from 90 to 100 residents. The Human Resource Director confirmed that the DON covered these shifts due to a staffing shortage after a weekend supervisor quit. Further investigation into the PBJ Report for the fiscal year quarter 2, 2024, showed that the facility triggered for no RN hours on several dates, with the previous DON working as the only RN on days when the census was over 60. The facility's policy requires the utilization of RN services for at least 8 consecutive hours per day, 7 days per week, which was not adhered to. Interviews with the DON and the Vice President of Clinical Services (VPCS) revealed a lack of clarity and planning regarding RN coverage, contributing to the deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to maintain required RN coverage for at least eight consecutive hours daily and did not have a full-time DON actively working on site. Staff time records showed days with no documented continuous RN presence, despite the facility’s own assessment requiring a full-time DON, ADON, wound care nurse, and MDS nurse. CNAs and other staff reported there was no nursing management (DON, ADON, MDS, or wound care nurse) in the building, no one to report concerns to, and poor communication, including new admissions arriving without notice. Human resources confirmed the prior DON left before completing a notice period, the ADON resigned immediately, and key nursing positions remained vacant, while an LPN and other staff stated that RNs were listed on schedules and PPD sheets but often were not physically present.
The facility failed to provide required RN coverage for at least eight consecutive hours per day, seven days a week, as shown by staffing schedules and timecard punches indicating no RN on duty on two days during a reviewed period, while 97 residents were present on each of those days. The DON confirmed in an interview that there was no RN coverage on those dates and that she was the only RN in the building, and the overall census was 107 residents. This deficiency was investigated under two complaint numbers.
The facility did not ensure eight consecutive hours of RN coverage per day, with time records showing only partial or no RN presence on certain days. The DON confirmed the lack of required RN coverage and was unaware of the federal requirement until interviewed.
The facility did not provide eight consecutive hours of RN direct care coverage on three days within a week, with the DON acting as the only RN present and providing resident care. Staffing records and staff interviews confirmed the absence of other RNs, and the facility lacked a policy on RN coverage requirements. This deficiency had the potential to affect all residents.
The facility did not employ a full-time DON dedicated solely to the skilled nursing facility, instead assigning the DON to oversee both the SNF and ALF. Interviews with staff and review of records confirmed that the DON has been responsible for both areas and could not specify the time spent on each, contrary to facility policy requiring a full-time DON for the SNF.
The facility did not have a dedicated, full-time DON after the DON went on medical leave, instead assigning the only MDS nurse to serve as acting DON while continuing her MDS duties. This resulted in the absence of a full-time DON as required, potentially impacting all residents.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to employ and have an actively working full-time Director of Nursing (DON). Review of staff clock-in times and resident records showed no documentation of an RN being in the building for eight consecutive hours on 02/21/26 or 03/08/26. The facility assessment dated 01/30/26 stated the facility must have a full-time DON, full-time Assistant DON (ADON), full-time wound care nurse, and full-time MDS nurse, but these positions were not filled or actively working in the facility during the survey period. Multiple staff interviews confirmed the absence of key nursing leadership and RN coverage. CNAs reported there was no DON, ADON, MDS nurse, or wound care nurse in the facility and that there was no nursing management available to report issues or concerns to. Human resources staff stated the previous DON gave a 30‑day notice but stopped working before the end of the notice period, and the ADON resigned effective immediately, leaving those positions vacant; positions for MDS nurse, wound care nurse, and ADON remained open. An LPN reported the facility was short on RN hours, that RNs were scheduled but often did not show up or quit, and that the situation worsened without a DON or ADON in the building. Other staff confirmed the facility was not meeting required RN hours, that RN names were placed on schedules and PPD sheets without the individuals being physically present, and that no corporate nurses came in to fill in for the DON or ADON.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required, potentially affecting all 107 residents. Review of staffing schedules and staff timecard punches for the period 12/25/25 through 12/31/25 showed that no RN worked in the facility on 12/25/25 and 12/31/25, despite census data indicating that 97 residents were in the facility on each of those days. During an interview on 02/24/26 at 3:18 P.M., the DON confirmed there was no RN coverage on those two dates and stated she was the only RN in the building on those days. This deficiency was investigated under Complaint Numbers 2671148 and 2603969. The deficiency centers on the absence of required RN coverage on specific days, as evidenced by staffing records, timecard punches, and census data, and confirmed by the DON’s interview, in the context of a facility census of 107 residents overall and 97 residents present on the days without RN coverage.
Failure to Provide Required Consecutive RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of registered nurse (RN) coverage per day, affecting all 73 residents. On one occasion, time sheets showed that two RNs worked overlapping shifts, but their combined consecutive hours only totaled seven hours and 36 minutes, falling short of the required eight consecutive hours. Additionally, on another day, there was no evidence that any RN was scheduled or worked at the facility at all. The Director of Nursing confirmed during interviews that there was no RN coverage for the required period on these days and was unaware of the federal regulation mandating eight consecutive hours of RN coverage until the time of the interview. No specific resident medical histories or conditions were mentioned in relation to the deficiency.
Failure to Provide Required RN Coverage and Improper Use of DON as RN
Penalty
Summary
The facility failed to provide eight consecutive hours of Registered Nurse (RN) direct care coverage on three specific dates within a seven-day period, as required by regulation. Staffing reports and staff time punch records confirmed that no RN was scheduled or present for the required hours on those dates. The Regional Director of Nursing (DON) was the only RN in the building and was providing resident care during these times. Interviews with the Regional DON and Staffing Coordinator confirmed that no other RNs were present on the identified dates. Additionally, the facility did not have a policy regarding RN coverage requirements, although the Administrator acknowledged awareness of the regulatory requirement for 8 hours of consecutive RN coverage daily and that the DON could not serve as the facility's RN coverage. This deficiency had the potential to affect all 94 residents in the facility. No specific details about individual residents' medical history or conditions at the time of the deficiency were provided in the report.
Failure to Employ Full-Time DON for Skilled Nursing Facility
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) solely for the skilled nursing facility (SNF), as required. Staff interviews confirmed that the DON has been responsible for both the SNF and the assisted living facility (ALF) for the past two years, and the DON herself was unable to specify how much time she spends on each area weekly. The Licensed Nursing Home Administrator and Director of Human Resources both confirmed that the DON was officially assigned to oversee both the SNF and ALF full time. Review of facility policy and the DON job description indicated that the DON is expected to assume full authority, responsibility, and accountability for nursing services in the facility, and that a registered nurse should be designated as DON on a full-time basis for the SNF. This deficiency had the potential to affect all 71 residents in the facility.
Lack of Dedicated Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a dedicated Registered Nurse (RN) to serve as the full-time Director of Nursing (DON), as required. The DON had been on medical leave and absent from the facility since 07/22/25. In response, the facility assigned the only MDS nurse, RN #300, to act as the interim DON while she continued to perform her full-time MDS duties. Interviews with the Administrator, Social Services Director, and Assistant Director of Nursing confirmed that RN #300 was the sole MDS nurse and was responsible for both the MDS and DON roles during this period. Review of the DON job description indicated that the DON is responsible for planning, organizing, developing, and directing the day-to-day functions of the nursing department and ensuring compliance with relevant regulations. The dual assignment of RN #300 to both the MDS and acting DON roles meant that the facility did not have a dedicated, full-time DON as required, potentially affecting all 67 residents in the facility.
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