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F0727
F

DON Did Not Meet Full-Time Hour Requirement

Soldotna, Alaska Survey Completed on 06-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the designated Director of Nursing (DON) worked the required 40 hours per week as stipulated by regulation. Interviews with the DON revealed that she was also serving as the facility Administrator and divided her workweek into 35 hours for DON duties and 5 hours for Administrator duties. The DON confirmed that she did not complete a timecard and was not required to clock in, instead allocating her time based on her own schedule. A review of the position description indicated that the role required a minimum of 35 hours per week for DON responsibilities, but the regulation cited (F354) requires a full-time DON, which is generally interpreted as 40 hours per week. Handwritten notes attached to the position description confirmed the division of hours between DON and Administrator roles. This practice resulted in the DON not fulfilling the full-time requirement for the DON position, as observed and documented by surveyors.

See complete original report
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