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F0727
E

Failure to Maintain Required RN Coverage and Improper Assignment of DON as Charge Nurse

Woodstock, Virginia Survey Completed on 09-26-2025

Penalty

No penalty information released
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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

Facility staff failed to provide required registered nurse (RN) coverage for at least eight consecutive hours per day on multiple dates, as evidenced by a review of nursing schedules and staff interviews. Specifically, there was no RN coverage for eight consecutive hours on five separate days, and the director of nursing (DON) confirmed that only one other RN was employed at the facility besides herself. The facility's own policy requires RN coverage for at least eight consecutive hours per day, seven days per week, but this standard was not met for 16 out of 31 days reviewed. Additionally, the DON served as a charge nurse on several occasions when the resident census exceeded 60, which is contrary to facility policy stating that the DON may only serve as a charge nurse when the average daily occupancy is 60 or fewer residents. Nursing schedules and staffing postings confirmed that the DON acted as charge nurse on multiple dates despite the higher census. The DON acknowledged that she was aware of the policy but felt compelled to serve as charge nurse due to staffing shortages.

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