Staffing Deficiencies and DON Role Mismanagement
Summary
The facility failed to provide a full-time Director of Nursing (DON) who did not serve as a charge nurse, despite having a census over 60 residents. The facility's policy required a full-time DON and stipulated that the DON could only serve as a charge nurse when the facility's average daily occupancy was 60 or fewer residents. However, the facility's staffing sheets revealed that the DON frequently worked as a charge nurse, even when the census was as high as 98. This was a clear violation of the facility's policy and federal regulations. Additionally, the facility did not maintain eight consecutive hours of Registered Nurse (RN) staffing daily on at least two occasions. On January 11 and 12, 2025, the staffing sheets showed no RN coverage for eight consecutive hours, which is a requirement for the facility. The facility's assessment indicated that federal regulations required 3.48 hours per resident day of direct care, with 0.55 hours from RNs, but the facility failed to meet this requirement on those days. Interviews with the DON and the administrator revealed that the facility had been struggling with staffing issues. The DON reported working almost every day as a charge nurse and being unable to fulfill her administrative duties. The facility had previously relied on agency staff to fill charge nurse roles, but this practice stopped on January 1, 2025. The administrator confirmed that the DON worked the floor most of February and was only able to perform her DON role for two days that month. The Regional Director of Operations acknowledged the staffing challenges and mentioned the possibility of bringing agency staff back to the facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure RN coverage for at least 8 consecutive hours on 3 of 46 days reviewed. Review of the Direct Care Staff Daily Reports showed no required RN coverage on three dates, and the Administrator acknowledged the missing coverage.
No full-time RN DON was designated in the facility. Staff, including an RN, an LPN, the ADON, and the Administrator, stated there was no current DON, and the Regional Nurses were not at the facility full time because they covered multiple facilities. The facility had 55 residents, all requiring skilled nursing services.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week. Review of the nursing schedule and staff time punches showed no RN present in the facility, and the Administrator confirmed he could not provide evidence that an RN worked the required 8 hours. The deficiency had the potential to affect all 95 residents.
RN Coverage Not Maintained on Scheduled Shifts: The facility failed to ensure an RN was present for 8 consecutive hours each day. Review of schedules and timecards showed LPNs covered the shifts on two dates when no RN was scheduled, and staff interviews confirmed the facility had difficulty hiring nurses and relied on last-minute coverage. The facility reported a census of 49 residents on one date and 50 residents on another, including 3 residents receiving Medicare skilled services.
RN Coverage Not Provided for Required Daily Hours: The facility failed to provide an RN for 8 consecutive hours per day, 7 days per week. The only RN on duty worked only a few hours on two days, and staff confirmed no agency RNs were used that weekend. Staff also stated there was no staffing policy and that the facility followed state regulations for staffing. The facility census documented 121 residents.
The facility failed to maintain RN coverage for at least 8 consecutive hours per day, 7 days a week. Record review showed no RN coverage on two weekend days, and the DON stated the usual weekend RN was on vacation and she could not cover those shifts. The Administrator stated the facility had no policy for RN coverage and deferred to HHSC regulations.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure a registered nurse was available for at least eight consecutive hours on 3 of 46 days reviewed for RN coverage. Review of the Direct Care Staff Daily Reports for 1/31/26 through 3/17/26 identified no required RN coverage on 1/31/26, 2/25/26, and 3/17/26. The report states this placed residents at risk for delayed nursing assessments. On 8/6/26 at 3:22 PM, the Administrator acknowledged the dates without the required RN coverage.
No Full-Time RN Director of Nursing
Penalty
Summary
The facility failed to designate a Registered Nurse as a full-time Director of Nursing. During the survey period on 7/22/26, 7/23/26, 7/27/26, 7/28/26, 7/29/26, and 7/31/26, surveyors found that there was no designated DON working in the facility. On 7/28/26, a Registered Nurse stated the facility did not currently have a DON, and a Licensed Practical Nurse stated the facility did not currently have a DON but had a Regional Nurse checking on things. On 7/28/26, a Regional Nurse stated that she was not at the facility full time because she was responsible for multiple facilities, and another Regional Nurse was likewise not at the facility full time for the same reason. The Assistant DON stated there was not a designated DON at the facility and neither Regional Nurse was there full time. The Administrator later stated the facility did not have a designated DON and that during approximately forty-five days of employment, there had not been one. The facility license showed a 64-bed skilled nursing facility, and the resident roster dated 7/22/26 showed 55 residents residing in the facility, all requiring skilled nursing services.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Review of the nursing staff schedule and staff time punches for 06/06/26 showed there was no RN present working in the facility. During an interview on 07/28/26 at 10:18 A.M., the Administrator confirmed that he was unable to provide evidence that an RN was working for at least eight consecutive hours on 06/06/26. The deficiency was identified under Complaint Numbers 2735166, 2715490, and 1405090 (OH00167146) and had the potential to affect all 95 residents residing in the facility.
RN Coverage Not Maintained on Scheduled Shifts
Penalty
Summary
The facility failed to ensure an RN was in the facility for eight consecutive hours seven days a week. Based on review of nursing schedules, time detail reports, and staff interviews, the facility had shifts covered by LPNs on 5/24/26 and 7/5/26 without an RN scheduled. On 5/24/26, Staff D, an LPN, worked from 4:57 AM to 5:31 PM and Staff E, an LPN, worked from 4:55 PM to 5:26 AM the next day, and the schedule lacked an RN. On 7/5/26, Staff D, an LPN, worked from 5:02 AM to 5:20 PM and Staff F, an LPN, worked from 5:00 PM to 5:19 AM the next day, and the schedule again lacked an RN. The facility reported a census of 49 residents on 5/24/26 and 50 residents on 7/5/26, including 3 residents receiving Medicare Skilled services. The DON stated the facility was unable to hire nurses, and the Administrator stated the staffing agency did not notify the facility when an RN called off and that coverage was often obtained at the last minute.
RN Coverage Not Provided for Required Daily Hours
Penalty
Summary
The facility failed to provide the services of a Registered Nurse for eight consecutive hours per day, seven days per week. On 7/4/26, the only RN on duty, V101, clocked in at 10:50 AM and clocked out at 12:59 PM for a total of 2 hours and 9 minutes. On 7/5/26, V101 clocked in at 10:00 AM and clocked out at 11:45 AM for a total of 1 hour and 45 minutes. The Human Resource Director confirmed that V101 was the only RN on duty on those dates, and the Regional Nurse Consultant stated that no agency RNs were used that weekend. The Regional Nurse Consultant also stated the facility did not have a staffing policy and followed state regulations for staffing. Another staff member confirmed there was no Regional Nurse Consultant present because it was a holiday weekend unless there was an emergency. The facility's daily census sheet dated 7/13/26 documented 121 residents in the facility.
Missed RN Coverage on Weekend Shifts
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. Record review of June 2026 Time Sheets and July 2026 Time Sheets showed the facility did not have the required RN coverage on 06/13/26 or 06/14/26. During an interview on 07/27/26 at 1:10 PM, the Director of Nursing stated the staff member who typically provided weekend RN coverage was on vacation on 06/13/26 and 06/14/26, and she was unable to provide coverage that weekend. She stated the facility attempted to obtain coverage from other staff members without success and that the expectation was to maintain at least 8 hours of consecutive RN coverage per day. During an interview on 07/27/26 at 1:40 PM, the Administrator stated the facility did not have a policy on utilizing an RN for 8 hours per day, 7 days per week and deferred to HHSC regulations.
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