Failure to Provide Full-Time DON Coverage When Census Exceeded 60
Penalty
No penalty information released
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 provide a full-time Director of Nursing (DON) who did not serve as a charge nurse when the facility census exceeded 60 residents, with the census documented at 86 and 87 on the affected dates. Review of staffing sheets revealed that there was no DON coverage on multiple dates in June 2025. Interviews with the DON and administrator confirmed that the DON had been reassigned to charge nurse duties due to staffing shortages, and the interim administrator, who was acting as DON, was absent from the facility for several days, resulting in no DON coverage during those times. The facility's own policy required a full-time DON, and this requirement was not met on the specified dates.