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F0839
F

Interim DON Practiced with Lapsed RN License

Warrensville Heights, Ohio Survey Completed on 12-18-2025

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 ensure that nursing staff were licensed in accordance with state laws, specifically allowing an individual to serve as Interim Director of Nursing (DON) while her Registered Nurse (RN) license was inactive and had lapsed. The Interim DON assumed the role in October 2025 after the previous DON resigned. Verification on the Ohio e-licensure website confirmed that the Interim DON's license had expired as of 10/31/25 and was not renewed. Despite reminders posted at the time clock and direct assistance from Human Resources (HR) to complete the renewal application, the license remained inactive due to incomplete renewal. Interviews with the Administrator and HR revealed that both were unaware the Interim DON's license was still inactive, even after attempts to prompt renewal. HR had assisted the Interim DON with the application process, but did not follow up to ensure completion. The deficiency was identified during a complaint investigation and had the potential to affect all 83 residents in the facility, as the Interim DON continued to practice without an active nursing license.

See complete original report
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