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 consecutive hours per day, seven days a week, as required by regulation and facility policy. Review of the May and June 2025 nurse schedules and employee timecard reports revealed multiple days where no RN was scheduled or present, and several days where the Director of Nursing (DON) was scheduled as the RN but worked less than the required eight hours. Specifically, on several dates in May and June, there was either no RN coverage or the DON worked between 5.25 and 7.5 hours instead of the mandated eight hours. Interviews with the DON and the Administrator in Training confirmed awareness of the RN staffing shortages, attributing the issue to a recent RN resignation and ongoing recruitment efforts. The facility did not utilize agency staffing to fill these gaps. At the time of the deficiency, 34 residents were residing in the facility, as documented in the Minimum Data Set (MDS) Resident Matrix.