Unqualified Individual Serving as Director of Nursing
Summary
The facility failed to ensure that the Director of Nursing (DON) was a registered nurse (RN) for a period of seven months. During an observation and interview, it was revealed that the individual serving as the DON was wearing a badge indicating their position but admitted to being an acting DON since March 2024. This individual had completed their schooling to become an RN but had not yet taken the National Clinical Licensure Examination (NCLEX) to obtain RN licensure. Consequently, the acting DON was not qualified as an RN, which is a requirement for the position according to the facility's job description. The facility's administrator confirmed that the job description for the DON required the individual to be a registered nurse in good standing with the State Board of Nursing. Despite this requirement, the acting DON was a Licensed Vocational Nurse (LVN) and had been in the position for over six months. The facility's staff roster and daily staffing sheet both listed the individual as the DON without indicating an acting position, further highlighting the discrepancy. This situation had the potential to result in inadequate supervision and management of the facility's residents and nursing staff due to the lack of a qualified RN in the DON role.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility did not ensure that an RN was on duty for at least 8 consecutive hours per day as required. Review of nursing schedules over a three-week period showed multiple days without 8 consecutive hours of RN coverage. During an interview, the staffing coordinator reported being unaware that RN coverage hours had to be consecutive, resulting in noncompliance with RN staffing requirements that could affect all residents needing higher-level nursing assessment or intervention.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
The facility failed to maintain the required eight consecutive hours of RN coverage per day on multiple occasions, despite having a census of fewer than 60 residents. Review of PBJ reports, daily census postings, staffing sheets, and timecards showed that on several days no RN was scheduled or worked the required continuous hours. The Administrator, who is responsible for ensuring RN coverage, acknowledged ongoing difficulties in maintaining this requirement, citing reliance on agency RNs and the unavailability of the prior DON when agency RNs did not report for their scheduled shifts.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Provide Required Consecutive RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered professional nurse (RN) for at least 8 consecutive hours per day as required. Review of the three-week nursing schedule dated 3/8/26 through 3/28/26 showed that on 3/14/26, 3/15/26, and 3/28/26, the facility did not provide 8 consecutive hours of RN coverage. This deficiency was identified through record review of the posted nursing schedules and confirmed during an interview on 4/2/26 at 9:47 AM, when the Staffing Coordinator stated she was unaware that the required RN hours must be consecutive. The report notes that this failure had the potential to affect all residents in the facility who may require a higher level of nursing assessment or intervention, but does not provide specific resident examples or clinical details.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required. Review of the Payroll Based Journal (PBJ) reports for the federal fiscal third and fourth quarters of 2025 showed days without the required RN coverage. Daily census posting sheets from April through September 2025 documented a consistent census of fewer than 60 residents and confirmed that on multiple specific dates there was no RN coverage for eight consecutive hours. Daily nursing staffing sheets for the same period also showed that no RN was scheduled for at least eight consecutive hours on those dates, and timecard records confirmed that no RN actually worked eight consecutive hours on those days. During an interview, the Administrator stated she was responsible for ensuring that an RN was scheduled to work eight consecutive hours each day and acknowledged ongoing difficulties in maintaining this required coverage since she began her role. She reported that the facility relied on agency nurses to fill RN shifts, and when an agency RN did not report for a scheduled shift, she was often unable to secure a replacement. She also noted that the previous Director of Nursing was unavailable during these times, which contributed to the gaps in the required RN coverage.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
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