Failure to Provide Required RN Coverage and Resulting Care Delays
Penalty
Summary
The facility failed to provide a registered nurse (RN) on duty for at least eight hours a day during weekends, as required. Staffing record reviews for March, April, and May 2025 revealed that on the majority of days, there was no RN coverage for the required hours, with 27 out of 31 days in March, 25 out of 30 days in April, and 23 out of 29 days in May lacking the necessary RN presence. Interviews with staff, including the Scheduler Coordinator and Interim Director of Nurses (DON), confirmed ongoing nurse staffing shortages and reliance on assistant directors of nursing (ADONs), only one of whom is an RN, to attempt to fill coverage gaps. The facility's MDS staff, who are RNs, do not provide direct care and are not consistently included in the staffing numbers reported. Resident council minutes and interviews indicated that residents experienced significant delays in call light response, sometimes waiting up to three hours, and reported that care assistants would turn off call lights without resolving issues. Additionally, there were observations of nurses leaving medications on tray tables without ensuring residents took them. These findings were corroborated by both staff and resident council feedback, highlighting the direct impact of insufficient RN coverage on resident care and medication administration.