Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours each day, 7 days a week, as required by licensure staffing requirements. Review of daily staffing schedules and time punches from January through June 2025 revealed multiple days each month where no RN was present for the required 8 consecutive hours. On several occasions, RNs worked only 7 hours and 45 minutes, resulting in insufficient RN coverage. The deficiency was identified for 111 out of 160 days reviewed. Interviews with facility staff confirmed these findings. The Assistant Director of Nursing (ADON) stated she is responsible for scheduling and confirmed that the Director of Nursing (DON) is only scheduled for 4 hours each day, Monday through Friday. The Administrator acknowledged that both the DON and the facility owner, who are RNs, could provide coverage if needed, but also confirmed that the facility does not have a staffing waiver in place.