Failure to Ensure RN Completion of Admission and Readmission Assessments
Summary
The facility failed to ensure that admission and readmission assessments for two residents were completed by Registered Nurses (RNs) as required. Instead, Licensed Vocational Nurses (LVNs) performed these assessments, including head-to-toe and skin assessments, without RN verification or involvement. Interviews with staff confirmed that LVNs typically conducted admission assessments, and RNs were not routinely involved in this process, contrary to facility policy and federal regulations. For one resident, the admission record showed initial admission and subsequent readmission with multiple diagnoses, including lumbar fracture, spinal stenosis, and obstructive uropathy. The resident was sent to the hospital for evaluation of skin tears and returned the same day, but no readmission assessment was completed by either an LVN or RN upon return. Staff interviews revealed that assessments were not always performed after hospital returns, and the importance of such assessments was acknowledged by the staff. Another resident was admitted and later readmitted with diagnoses such as Parkinson's disease, diabetes, and dementia. The admission/readmission evaluation was completed by an LVN, and staff interviews confirmed that LVNs generally performed these assessments. The Director of Nursing stated that RNs do not usually do admissions, and if an LVN completes the assessment, the RN should verify it, but this was not consistently done. Facility policies indicated that RNs are responsible for comprehensive assessments and oversight of care plans, but these procedures were not followed in practice.
Plan Of Correction
F-tag 727 (1) Corrective Action for residents found to have been affected: • Resident 21 was no longer in the facility as of 05/22/2025. • Resident 28 admission/readmission evaluation was completed by the licensed nurse on 05/13/2025 and reviewed by the DON on 05/19/2025. II. Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • The MRD completed an audit on 06/06/2025 for the past 14 days, that an admissions/readmission evaluation was completed by licensed nurses. No other residents are affected by the deficient practice. III. Measures and systemic changes put in place to ensure deficient practices do not recur: • On 05/18/2025, the DON conducted an in-service to facility licensed nurses regarding completion of admission/readmission evaluation of residents. The goal is to ensure that there is no delay of care and services due to missed or inaccurate identification of problems. • The MRD will conduct daily audits for completion of admissions/readmission evaluation of residents by licensed nurses and validated by RN. Findings will be reported to the Director of Nursing during daily stand-up meetings for follow-up. IV. Facility's plan to monitor corrective actions, achieve, and sustain compliance; integrate the POC to QA process: • The Medical Record Director/designee will report the findings and trends of weekly audits of admissions/readmission evaluation of residents completed by a licensed nurse during the monthly QA meeting for the next 3 months to ensure compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Maintain Required RN Coverage: The facility did not have an RN in the building for at least 8 consecutive hours a day, 7 days a week on multiple dates. Administrative Nurse D verified that no RN was present for the required coverage or serving as charge nurse on those dates, despite the facility policy requiring daily RN coverage and a full-time DON.
Failure to Maintain Required RN Coverage: The facility failed to ensure an RN was on duty for at least 8 consecutive hours a day, 7 days a week on multiple reviewed days. Daily HR reports showed zero RN hours worked on several dates, and both the DON and ADM stated they could not explain why RN coverage was absent, while acknowledging the requirement for daily RN coverage and the administrator's responsibility for staffing.
RN and DON Coverage Not Maintained: The facility failed to ensure an RN served as DON on a full-time basis and failed to maintain RN coverage for at least eight consecutive hours each day. Staffing schedules, timecards, and staff interviews showed no RN worked on two days and no DON was present for several days. Interviews also confirmed the DON coverage was intermittent, with one RN serving only on limited days and another stating she had no documentation showing she worked in the facility after the prior DON left.
Lack of Documented Daily RN Coverage: Surveyors found that the facility did not have documented RN coverage scheduled for at least 8 consecutive hours per day, 7 days a week. Review of staffing postings showed multiple days without the required RN coverage, and the ANHA stated there were no other documents available to verify RN coverage. No policy was provided by the end of the survey.
RN Coverage Not Maintained: The facility failed to ensure RN services for at least 8 consecutive hours per day, 7 days a week. Time records showed missing RN coverage on multiple days, and the DON and ADM acknowledged that RN staffing hours were absent at times. The facility policy required RN coverage and allowed DON hours to count toward the requirement.
RN Coverage Not Maintained as Required: The facility failed to maintain RN coverage for at least 8 consecutive hours per day. Record review showed multiple days with no RN in the building within a 24-hour period and other days with less than 8 consecutive hours of RN coverage. Interviews confirmed the Staffing Coordinator and DON leadership understood the coverage expectation differently, and the facility sometimes relied on an on-call RN to come in if issues arose.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Review of the Registered Nursing Staffing Schedule for March 2026, April 2026, and May 2026 showed the facility lacked an RN on 03/16/26, 03/21/26, 03/22/26, 04/04/26, 04/18/26, 05/02/26, 05/03/26, 05/16/26, 05/23/26, 05/24/26, and 05/31/26. On 06/03/26 at 09:00 AM, Administrative Nurse D verified that the facility did not have an RN in the building for eight consecutive hours or working as a charge nurse on those dates. The facility's RN policy, dated January 2024, stated the facility would employ an RN for at least eight consecutive hours a day, seven days a week and would designate an RN to serve as the DON on a full-time basis, with the DON serving as charge nurse only when the average daily census was 60 or fewer residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week on 10 of 15 days reviewed for RN coverage. Review of the daily HR total employee hours reports provided by the ADM showed zero RN hours worked on 10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25, and 12/28/25. The report stated the facility failed to ensure RN coverage on those dates and that this could place residents at risk of missed nursing assessments, interventions, care, and treatment. During interview, the DON stated she was not the DON during the dates with no RN coverage and could not explain why there was no RN coverage because she started in February 2026. She stated the facility was required to have 8 consecutive hours every day, 7 days a week of RN coverage and that being without an RN was unacceptable. During interview, the ADM stated he did not know why there were no RN hours on the listed dates because he started as administrator in March 2026, but acknowledged the expectation of at least 8 RN hours daily and stated it was ultimately the administrator's responsibility to ensure staffing coverage. He also stated he could not find documentation showing an RN was in the facility for the required 8 hours and that there was no facility policy specific to RN hours, only state and federal guidelines.
RN and DON Coverage Not Maintained
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was designated as the Director of Nursing (DON) on a full-time basis and failed to ensure an RN was working in the facility at least eight consecutive hours per day, seven days a week. Review of staffing schedules and timecard reports for 05/03/26 through 05/09/26 showed that an RN did not work on 05/07/26 and 05/08/26. Review of the same records also showed that a DON was not present in the facility from 05/05/26 through 05/09/26. During interviews, LPN #55 stated the facility did not currently have a DON and described RN, DON #82 as coming every Wednesday to serve as both DON and RN, while RN, DON #84 came two days a week to serve as DON. RN #79 stated she was unaware of how often RN, DON #84 was in the facility. RN, DON #84 stated she was the Regional Nurse, did not punch a clock, and had no documentation showing she had worked in the facility since the previous DON left on 04/29/26. RN, DON #82 stated she did not work in the facility at all from 05/03/26 to 05/09/26, and RN, DON #83 stated she only worked on 05/04/26. The DOO verified that RN, DON #83 was only in the facility on 05/04/26, that RN, DON #82 was only in the building on 05/13/26 and 05/20/26, and that there was no DON coverage in the facility from 05/05/26 through 05/09/26. The DOO also verified there was no RN in the facility on 05/07/26 and 05/08/26 as required.
Lack of Documented Daily RN Coverage
Penalty
Summary
The facility failed to have documented RN coverage scheduled for at least eight consecutive hours per day, seven days a week. During the Staffing Task of the survey, surveyors requested six months of Daily Staffing Census/Postings, and the postings provided showed multiple dates without eight consecutive hours of RN coverage, including 3/5, 3/6, 3/7, 3/8, 3/28, 3/29, 3/31, 4/14, 4/21, 4/24, and 4/28/2026. On 5/21/2026 at 3:12 PM, the Acting Nursing Home Administrator stated there were no other documents available to review for RN coverage. The facility did not provide a policy addressing the concern by the end of the survey.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure 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 RN coverage. Record review of the resident roster dated 05/18/2026 showed a census of 54 residents. Record review of the facility's time detail from April 2026 to May 2026 showed the facility did not have an RN working for a total of 8 hours on 04/11/2026, 04/12/2026, and 05/10/2026. During interview, the DON stated there were days when 8 hours of RN staffing hours were missing and said RN staff were important because they provided a supervisory role to LVNs and CNAs. The ADM also stated it was important to have an RN work 8 hours per day because of the additional training an RN received and said the facility was in the process of hiring more RNs. Record review of the facility's policy, Nursing Services-Registered Nurse (RN), revised 02/2026, reflected the facility would utilize the services of an RN for at least 8 consecutive hours per day, 7 days per week, and that the hours worked by the DON would count toward the requirement.
RN Coverage Not Maintained as Required
Penalty
Summary
The facility failed to use the services of a registered nurse for at least eight consecutive hours per day, seven days per week. Review of Employee Paired Punches from 12/01/2025 to 05/05/2026 showed no registered nurse in the building within a 24-hour period on 12/15/2025, 12/16/2025, and 12/18/2025, and less than eight consecutive hours of registered nurse coverage on 12/17/2025 and 02/24/2026. During interviews, the Staffing Coordinator stated that a registered nurse had to be in the building for at least eight hours per day, but the hours did not have to be consecutive. The Regional Director of Nursing stated they were aware that there had to be a registered nurse in the building for eight out of 24 hours, were aware there were times with no registered nurse in the building, and that the facility occasionally used an on-call registered nurse who would come in if there were issues. The Administrator stated they were not aware of the lack of registered nurse coverage.
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