Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of 8 consecutive hours per day, 7 days per week, as required. Review of facility schedules and timesheets for January, February, and March 2025 revealed that there was no RN coverage on six specific days across the three months. This deficiency had the potential to affect all 39 residents living in the facility. Interviews with the director of nursing (DON) and the administrator confirmed that staffing hours were reviewed daily and discussed in interdisciplinary team meetings, but gaps in RN coverage still occurred. The facility's policy required RN coverage as specified, and the DON could serve as a charge nurse when daily occupancy was 60 or fewer residents. The facility was also responsible for submitting accurate staffing data through the CMS payroll-based journal system.