Lack of Dedicated Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a dedicated Registered Nurse (RN) to serve as the full-time Director of Nursing (DON), as required. The DON had been on medical leave and absent from the facility since 07/22/25. In response, the facility assigned the only MDS nurse, RN #300, to act as the interim DON while she continued to perform her full-time MDS duties. Interviews with the Administrator, Social Services Director, and Assistant Director of Nursing confirmed that RN #300 was the sole MDS nurse and was responsible for both the MDS and DON roles during this period. Review of the DON job description indicated that the DON is responsible for planning, organizing, developing, and directing the day-to-day functions of the nursing department and ensuring compliance with relevant regulations. The dual assignment of RN #300 to both the MDS and acting DON roles meant that the facility did not have a dedicated, full-time DON as required, potentially affecting all 67 residents in the facility.