Failure to Provide Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight hours each day and did not have a full-time Director of Nursing (DON) present for eight specific days in November 2025. Record review showed that on these days, there was no RN or DON working at the facility during the 24-hour period. The absence of RN coverage was confirmed by both the Corporate RN and the Human Resources Director, who stated that the previous DON, who had provided daily RN coverage, was last employed on October 31, 2025. After this date, the Corporate RN attempted to visit the facility as much as possible but was not present daily, resulting in gaps in required RN coverage. Interviews with facility leadership, including the Administrator and Assistant Director of Nursing (ADON), acknowledged the necessity of having a DON or RN present to provide licensed nursing assessments of resident care needs and behaviors on a daily basis. The facility's own policy requires that an RN provide services at least eight hours every 24 hours, seven days a week. The deficiency was identified through observation, interviews, and record review, with no mention of specific residents or their medical conditions at the time of the deficiency.