Failure to Maintain Required RN and DON Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) on duty for at least eight hours per day, seven days per week, and did not have a Director of Nursing (DON) or interim DON onsite full-time for a minimum of 40 hours per week. Review of staffing records and facility assessment revealed that there was no RN or DON coverage on multiple days, specifically on 4/7/25 and 4/8/25, despite a census of 54 residents. Observations confirmed that only LPNs and CNAs were present during these times, with no RN or DON listed on posted staff rosters. The facility's staffing policy for RN and DON requirements was requested but not provided. Interviews with staff and regional leadership confirmed that the DON had resigned without notice, and there was no RN coverage on the days in question. Staff reported uncertainty about RN or DON presence and lacked contact information for regional nursing support. The interim DON arrived only after the period of non-compliance, and regional and corporate leaders acknowledged gaps in RN coverage and the absence of an acting DON onsite during the deficiency period. No residents requiring RN-specific care were identified at the time, but the required RN and DON coverage was not maintained as per regulatory requirements.