Failure to Designate a Full-Time Director of Nursing
Summary
The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis since November 3, 2024. This deficiency was identified through interviews and record reviews, which revealed that the last day of DON coverage was on November 3, 2024. The facility's administrator, who began employment on November 25, 2024, confirmed that there was no DON at the time of her hiring. Additionally, the Assistant Director of Nursing (ADON), who started on November 11, 2024, also confirmed the absence of a DON. Further investigation showed that the facility's policy requires the Nursing Services department to be managed by a full-time DON, who is a licensed RN with experience in nursing administration, rehabilitation, and geriatric nursing. Despite this requirement, the facility has been unable to employ a DON, as confirmed by the current administrator, who started his role on January 7, 2025. The absence of a DON could place residents at risk due to a lack of nursing oversight and a higher level of care.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to maintain required RN coverage for eight consecutive hours daily and did not have a current RN waiver in place. Review of staffing records showed one RN did not work during the review period and another worked only 7.3 hours over 14 days, while the DON and ADON usually worked weekdays but documentation of resident care was not available. The Administrator acknowledged the facility needed to hire additional RNs or apply and renew the waiver.
The facility did not timely or adequately request a waiver when unable to recruit a registered nurse for the DON position. After the previous DON resigned, the facility was without an RN in this role and failed to provide the State Agency with requested evidence of recruitment efforts or assurances for resident safety. The acting DON did not meet RN requirements.
The facility did not inform residents, their representatives, or family members about a waiver for the seven-day RN requirement, as admitted by the Chief Nursing Officer. This affected all 22 residents, despite the facility's policy on Resident Rights mandating such notifications.
The facility did not meet the federal requirement of having an RN scheduled for 8 consecutive hours daily on several occasions. Despite efforts to recruit staff, the facility relied on an on-call RN system, which did not fulfill the regulatory mandate.
The facility did not maintain 24-hour licensed nursing staff coverage for eight days in the first quarter of fiscal year 2024. The CASPER report showed 20 days without licensed staff, and the DON attributed this to payroll software issues. However, payroll records confirmed gaps of six hours or more on specific night shifts, and no information on the software problem was provided.
Failure to Maintain RN Coverage and Renew Waiver
Penalty
Summary
The facility failed to ensure a current RN waiver was completed when it did not have an RN on duty for eight consecutive hours daily during the 14-day review period from 12/23/25 through 01/05/26. Review of the Daily Staffing Report showed no RN coverage for the required daily eight-hour period, and the facility’s four RNs included the DON, the ADON, and two part-time RNs. Employee records showed RN #19 did not work at all during the review period, and RN #18 worked only 7.3 hours over the 14 days. The Administrator stated that the DON and ADON usually work Monday through Friday but could not provide documentation or state for sure that they performed resident care. The Administrator also stated the facility may apply for a waiver if it cannot meet RN staffing requirements due to difficulty hiring in a rural area, but the facility failed to re-apply for the waiver.
Failure to Timely Request and Support Waiver for RN DON Requirement
Penalty
Summary
The facility failed to request a waiver in a timely and complete manner when unable to meet the requirement of having a registered nurse serve as the Director of Nursing (DON). After the resignation of the previous DON, who was a registered nurse, the facility was without a registered nurse in this position for an extended period. Although the facility eventually submitted a waiver request, it did so several months after the vacancy began. The State Agency (SA) denied the initial waiver request and requested additional information to demonstrate diligent efforts to recruit appropriate personnel, evidence that a waiver would not endanger resident health or safety, and confirmation that a registered nurse or physician was available to respond to calls when licensed nursing services were unavailable. The facility did not respond to the SA's request for further information, nor did it submit an additional waiver request as instructed. During an on-site investigation, it was confirmed that the acting DON was not a registered nurse and did not meet state and federal requirements.
Failure to Notify Residents of RN Staffing Waiver
Penalty
Summary
The facility failed to notify residents, their representatives, and immediate family members about a waiver for the seven-day Registered Nurse (RN) requirement. This waiver, dated 04/16/2021, indicated that the facility did not have RN coverage seven days a week. Despite the facility's policy on Resident Rights, which mandates that residents be informed of all available services, the Chief Nursing Officer admitted on 02/04/2025 that no notifications had been made to the residents or their families regarding this waiver. This oversight affected all 22 residents residing in the facility.
Failure to Meet RN Staffing Requirements
Penalty
Summary
The facility failed to ensure compliance with the federal regulatory requirement of having a Registered Nurse (RN) scheduled for at least 8 consecutive hours a day, 7 days a week, as stipulated under 42 Code of Federal Regulations Section 483.35(b). Specifically, there were no RNs scheduled for 8 consecutive hours on four specific dates: 6/06/2024, 6/23/2024, 7/14/2024, and 9/28/2024. The facility's census was 80 at the time of the survey, and the review of the written working schedules confirmed the absence of an RN on these days. The facility had submitted a waiver request to the Department, citing their inability to recruit sufficient qualified nursing personnel despite extensive efforts, including offering sign-on bonuses, flexible opportunities, and outreach to nursing schools and agencies. The facility had an arrangement where an RN and a practitioner were available to respond to phone calls during periods when an RN was not physically present in the building. Additionally, the Director of Nursing and other registered nurses were on-call and lived nearby to address urgent medical needs. However, this arrangement did not meet the regulatory requirement of having an RN present for 8 consecutive hours each day.
Failure to Maintain 24-Hour Licensed Nursing Staff Coverage
Penalty
Summary
The facility failed to provide licensed nursing staff on a 24-hour basis for eight days in the first quarter of fiscal year 2024. The CASPER report identified 20 days between October 1, 2023, and December 31, 2023, when there was no licensed nursing staff present. During an interview on May 17, 2024, the Director of Nursing (DON) stated that the facility was currently well-staffed and attributed the gaps in the CASPER report to a malfunction in their payroll software. However, the facility's payroll records confirmed specific dates with gaps of six hours or more without licensed nursing staff coverage, particularly on night shifts. Information regarding the payroll software issue was requested but not provided.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.