Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) provided services for at least eight consecutive hours a day, seven days a week, as required. The Facility Assessment Tool for 12/2024 through 12/2025 documented that staffing for licensed nurses, including RNs, should follow the facility assessment and CMS minimum staffing rule and further specified that staffing should include one RN per shift. However, review of the Daily Nurse Staffing Sheets from 1/1/2026 through 1/20/2026 showed there was no RN coverage for at least eight consecutive hours on 1/3/2026, 1/4/2026, 1/11/2026, and 1/17/2026. On 1/21/2026 at 9:16 a.m., the Assistant Director of Nursing confirmed that there was no RN coverage for eight consecutive hours on those dates and stated that nursing management staff are on-call on weekends if needed. Resident Council Meeting Minutes from October, November, and December 2025 documented short staffing and staffing concerns, and the facility’s Midnight Census Report dated 1/15/2026 showed that 138 residents resided in the facility during this period. No specific resident medical histories or conditions were described in the report, but the deficiency was identified as having the potential to affect all 138 residents currently residing in the facility.
