Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, seven days a week, as required by regulation. Record review of the RN nursing schedule for November 2025 revealed that there was no evidence of 8-hour RN coverage on five specific days within the month. Both the Director of Nursing (DON) and the Administrator confirmed during interviews that there was no RN coverage on these dates. The DON stated that she could not cover every shift and acknowledged the lack of RN coverage on the identified days. The DON also indicated that the Assistant Director of Nursing (ADON) was responsible for completing the staffing schedule, while she monitored it. The Administrator, who started on the first day of the month, also confirmed the expectation for daily 8-hour RN coverage and stated that the DON was responsible for monitoring the schedule. The DON and Administrator both expressed that they did not believe there was a negative effect on residents due to the lack of RN coverage, citing staff access to the DON and communication channels such as a group chat with corporate staff. The DON attributed the failure to difficulties in hiring RNs willing to work with the facility's specific resident population, which included individuals from the penal system and/or sex offenders. The Administrator stated that the facility did not have a specific policy but followed federal and state regulations. There was no mention of any specific resident being directly affected or any adverse outcomes resulting from the deficiency.