Failure to Provide Required RN Coverage
Penalty
Summary
Facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required by both facility policy and federal regulations. Review of RN staffing assignments revealed that on multiple dates, including 06/11/25, 06/13/25, 06/22/25, 07/04/25, 07/07/25, 07/12/25, and 07/13/25, there was no RN present in the facility for the required duration. The facility census at the time was 46 residents. The facility's own assessment and policy documents confirmed the expectation to have at least one RN on duty for eight hours daily, but this standard was not met on the identified dates. Interviews with the Staffing Coordinator, interim DON, and administrator confirmed awareness of the requirement but revealed that staffing limitations contributed to the deficiency. The Staffing Coordinator stated that only one RN was available aside from the DON, and when the RN was scheduled off, attempts to have the DON cover the shifts were unsuccessful. The interim DON, who assumed the role on 07/14/25, was not aware of the missed RN coverage on the specified dates. The administrator, recently returned from vacation, was also unsure why the RN requirement was not met on those days.