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F0727
F

Failure to Designate Full-Time Director of Nursing

Duarte, California Survey Completed on 12-23-2025

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

The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis, as required, from December 9, 2025, to December 23, 2025. During this period, there was no RN working as a full-time DON, despite a census of 52 residents. Observations on December 22 and 23, 2025, confirmed the absence of a designated full-time DON. Interviews with the former DON, the Administrator, and several RNs revealed that the previous DON had resigned in early December, and since then, no RN had been assigned to the full-time DON role. Instead, oversight was provided by RN consultants who visited the facility only 8 to 24 hours per week, and floor RNs and LVNs were considered to be acting as DONs in their absence. Facility policy and job descriptions reviewed during the survey indicated that the DON must be a state-licensed RN with experience in nursing service administration and must be employed full-time (40 hours per week). The policies also specified that RNs report to the DON, and the DON is responsible for overseeing nursing services and ensuring compliance with regulations. Despite these requirements, the facility did not have a full-time DON in place during the specified period, as confirmed by staff interviews and policy review.

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