Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to provide RN coverage for eight consecutive hours per day, seven days per week, as required, on 21 of 78 reviewed days between August and November 2025. Review of the Direct Care Staff Daily Reports for 8/2025, 9/2025, 10/2025, and 11/2025 showed that on multiple specific dates in each of those months there was no RN documented as being on duty for the required eight-hour period. Staff interviews revealed that staff were only instructed to begin reporting the RN manager on the Direct Care Staff Daily Report starting 1/13/25, and the Administrator stated that staff were expected to call off work two hours before their shift to allow time to find coverage. Surveyors requested payroll documentation to verify RN work on the identified dates, but no additional documentation was provided, and the deficiency was cited as placing residents at risk for unmet assessment needs. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency was based on staffing records, staff interviews, and the absence of corroborating payroll documentation for RN coverage on the listed dates.
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