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F0727
F

Failure to Designate a Full-Time Registered Nurse as DON

Saint Paul, Minnesota Survey Completed on 12-30-2025

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 to serve as the director of nursing (DON) on a full-time basis after the previous DON was terminated. For approximately two weeks, an LPN was the only administrative staff on duty and had been acting as the DON, despite not being a registered nurse. Interviews with facility staff, including the Director of Human Resources and the Administrator, revealed uncertainty about who was currently fulfilling the DON role, with the corporate office handling the hiring process for a new DON. The facility was relying on a team approach involving the assistant director of nursing, nursing staff, and the President of Clinical Services to cover the responsibilities of the DON, but no one was officially designated or able to assume the role full-time. No facility policy regarding required nursing services was provided upon request.

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