Failure to Maintain Full-Time DON Results in Multiple Care Deficiencies
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was assigned to serve as a full-time Director of Nursing (DON) to coordinate nursing care and supervision for all 52 residents. According to the facility's records and staff interviews, the designated DON resigned and did not return to work after April 4, 2025, despite initially stating her resignation would be effective May 2, 2025. The facility did not receive an official resignation letter, and the DON did not perform her duties from April 4 onward. During this period, a corporate nurse visited only once a week, and there was no full-time RN serving as DON until a new DON was hired to start on April 22, 2025. During the survey conducted from April 15 through April 18, 2025, it was observed that the absence of a full-time DON led to deficiencies in several areas, including activities of daily living (ADL) care, urinary catheter care, intravenous (IV) care, oxygen therapy and care, medication labeling, controlled medication inventory and storage, addressing pharmacy recommendations, infection control surveillance, advance directives, and care plan development. These deficiencies affected all residents in the facility during the period without a full-time DON.