Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours a day, seven days a week, as required. Interviews with staff revealed that only one RN was scheduled as a floor nurse, while the other two RNs held administrative roles as the Director of Nursing (DON) and Assistant Minimum Data Set (AMDS) nurse, and were not utilized to provide direct resident care. Review of the staffing schedule for May 2025 showed that there were 11 days within a 21-day period when no RN worked an eight-hour shift, which was confirmed by the Assistant Director of Nursing (ADON). The facility's policy on staffing requires an RN to provide services for at least eight consecutive hours every 24 hours, seven days a week. Despite this policy, the facility did not have RN coverage for the required hours on multiple days, as documented in the staffing records and acknowledged by the ADON. This deficiency was identified through interviews and record reviews conducted by surveyors.