Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide sufficient registered nurse (RN) coverage for the second quarter of 2025, as required by federal regulations. Specifically, the facility did not have an RN on duty for at least 8 consecutive hours per day, 7 days a week, as evidenced by payroll-based journal (PBJ) records and staffing sheets. Signage posted at the main receptionist desk indicated that the facility did not meet minimum staffing ratios for the quarter ending March 31, 2025. The Director of Nursing (DON) confirmed that for 21 days during the second quarter, there was no RN present for the required 8 consecutive hours. Review of staffing sheets and time punches for January, February, and March revealed multiple days where RNs worked less than 8 hours, particularly on holidays and weekends, and on some days, time punch records were not made available for review. These deficiencies were corroborated through observations, interviews with the DON and RNs, and record reviews. The lack of consistent RN coverage had the potential to affect all residents in the facility, as there was not always an RN present for the required duration on several days throughout the quarter. No specific residents or their medical conditions were mentioned in the report.