Unlicensed DON Provided Nursing Oversight and Direct Care
Summary
The deficiency involves the facility’s failure to ensure that nursing services were provided by a licensed nurse when the Director of Nursing (DON1) worked while her nursing license was under temporary suspension. A document from the South Carolina Department of Labor Licensing and Regulation dated June 18, 2025, stated that DON1’s license to practice nursing in the state was temporarily suspended effective immediately, until further order of the Board. Despite this suspension, DON1 continued to work at the facility on June 18, 2025, and June 23, 2025, performing DON duties and providing nursing leadership oversight without a valid nursing license. The facility’s own job description for the Director of Nursing, signed by DON1, specified that the DON must be a registered nurse in good standing with the State Board of Nursing and responsible for overall management of the nursing department, staffing levels, resident safety, and direct resident care as needed. During the period of suspension, DON1 provided direct care and clinical oversight for at least two residents. For one resident (R4), the electronic medical record for June 2025 documented that on June 23, 2025, the resident approached DON1 to assess a large erythematous and ulcerated rash under the right pectoral area. The note indicated that the nurse practitioner and physician were made aware and examined the area, and that DON1 contacted the wound provider and obtained orders for Mycolog II cream twice daily for 14 days, Diflucan 100 mg by mouth daily for 5 days, Keflex 500 mg by mouth twice daily for 10 days, and Interdry application several hours after the cream. The documentation further showed that at 2:33 PM that same day, DON1 entered medication orders for Diflucan and Cephalexin for erythrasma, and later documented extensive interaction with the resident regarding showering and timing of leg wraps, including multiple reminders and an explanation of her need to leave the facility for an appointment. For another resident (R5), the electronic medical record for June 2025 showed that DON1 completed a weekly summary note and signed an interdisciplinary team (IDT) conference assessment on June 18, 2025, the same date her license suspension became effective. These entries indicated that DON1 was performing clinical assessment and documentation functions for this resident while not legally authorized to practice as a nurse. Human Resources staff later stated that they were unaware of the suspension at the time and that DON1, a salaried exempt employee who did not clock in and out, continued to perform typical DON duties during this period. The survey agency determined that the facility’s noncompliance with nursing services requirements, specifically allowing an unlicensed individual to function as the DON and provide direct resident care, constituted Immediate Jeopardy related to 42 CFR §483.35(c)(3) Nursing Services.
Removal Plan
- Notify the Medical Director of the Immediate Jeopardy and complete any additional required external notifications if applicable.
- Initiate a primary source audit of all currently employed licensed nursing staff to confirm active licensure and good standing; print/electronically save verification evidence and place it in personnel files.
- Complete a look-back investigation for all shifts worked by the ex-employee; assess/interview identified residents.
- Provide mandatory re-education to licensed nursing staff on the requirement to immediately notify the Administrator and/or DON of any license investigation, consent order, suspension, restriction, expiration, or other status change.
- Monitor compliance through QAPI; report results monthly for three months and quarterly for three additional quarters; QAPI Committee to re-evaluate need for further monitoring; Human Resource Director responsible for monitoring and follow-up.
- Upload current active nursing licenses for all licensed nursing staff into the facility’s human resources system to centralize and improve access to credential verification.
- Re-educate the Human Resources Director on the licensure certification and registration of personnel policy.
- Implement a process requiring all newly hired employees to sign an attestation that they must inform the Administrator/DON/HR Director of any licensure investigation, consent order, or change in licensure status; failure to report may result in discipline up to termination.
- Initiate an attestation for all currently employed licensed personnel regarding responsibility to report any licensure investigation, consent order, or change in licensure status; failure to report may result in discipline up to termination.
- Complete all attestations for licensed personnel; employees will not work until the attestation is completed.
- Implement a standardized license verification form and a central licensure tracking log with verification and expiration dates.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure RN coverage for at least 8 consecutive hours on 3 of 46 days reviewed. Review of the Direct Care Staff Daily Reports showed no required RN coverage on three dates, and the Administrator acknowledged the missing coverage.
No full-time RN DON was designated in the facility. Staff, including an RN, an LPN, the ADON, and the Administrator, stated there was no current DON, and the Regional Nurses were not at the facility full time because they covered multiple facilities. The facility had 55 residents, all requiring skilled nursing services.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week. Review of the nursing schedule and staff time punches showed no RN present in the facility, and the Administrator confirmed he could not provide evidence that an RN worked the required 8 hours. The deficiency had the potential to affect all 95 residents.
RN Coverage Not Maintained on Scheduled Shifts: The facility failed to ensure an RN was present for 8 consecutive hours each day. Review of schedules and timecards showed LPNs covered the shifts on two dates when no RN was scheduled, and staff interviews confirmed the facility had difficulty hiring nurses and relied on last-minute coverage. The facility reported a census of 49 residents on one date and 50 residents on another, including 3 residents receiving Medicare skilled services.
RN Coverage Not Provided for Required Daily Hours: The facility failed to provide an RN for 8 consecutive hours per day, 7 days per week. The only RN on duty worked only a few hours on two days, and staff confirmed no agency RNs were used that weekend. Staff also stated there was no staffing policy and that the facility followed state regulations for staffing. The facility census documented 121 residents.
The facility failed to maintain RN coverage for at least 8 consecutive hours per day, 7 days a week. Record review showed no RN coverage on two weekend days, and the DON stated the usual weekend RN was on vacation and she could not cover those shifts. The Administrator stated the facility had no policy for RN coverage and deferred to HHSC regulations.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure a registered nurse was available for at least eight consecutive hours on 3 of 46 days reviewed for RN coverage. Review of the Direct Care Staff Daily Reports for 1/31/26 through 3/17/26 identified no required RN coverage on 1/31/26, 2/25/26, and 3/17/26. The report states this placed residents at risk for delayed nursing assessments. On 8/6/26 at 3:22 PM, the Administrator acknowledged the dates without the required RN coverage.
No Full-Time RN Director of Nursing
Penalty
Summary
The facility failed to designate a Registered Nurse as a full-time Director of Nursing. During the survey period on 7/22/26, 7/23/26, 7/27/26, 7/28/26, 7/29/26, and 7/31/26, surveyors found that there was no designated DON working in the facility. On 7/28/26, a Registered Nurse stated the facility did not currently have a DON, and a Licensed Practical Nurse stated the facility did not currently have a DON but had a Regional Nurse checking on things. On 7/28/26, a Regional Nurse stated that she was not at the facility full time because she was responsible for multiple facilities, and another Regional Nurse was likewise not at the facility full time for the same reason. The Assistant DON stated there was not a designated DON at the facility and neither Regional Nurse was there full time. The Administrator later stated the facility did not have a designated DON and that during approximately forty-five days of employment, there had not been one. The facility license showed a 64-bed skilled nursing facility, and the resident roster dated 7/22/26 showed 55 residents residing in the facility, all requiring skilled nursing services.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Review of the nursing staff schedule and staff time punches for 06/06/26 showed there was no RN present working in the facility. During an interview on 07/28/26 at 10:18 A.M., the Administrator confirmed that he was unable to provide evidence that an RN was working for at least eight consecutive hours on 06/06/26. The deficiency was identified under Complaint Numbers 2735166, 2715490, and 1405090 (OH00167146) and had the potential to affect all 95 residents residing in the facility.
RN Coverage Not Maintained on Scheduled Shifts
Penalty
Summary
The facility failed to ensure an RN was in the facility for eight consecutive hours seven days a week. Based on review of nursing schedules, time detail reports, and staff interviews, the facility had shifts covered by LPNs on 5/24/26 and 7/5/26 without an RN scheduled. On 5/24/26, Staff D, an LPN, worked from 4:57 AM to 5:31 PM and Staff E, an LPN, worked from 4:55 PM to 5:26 AM the next day, and the schedule lacked an RN. On 7/5/26, Staff D, an LPN, worked from 5:02 AM to 5:20 PM and Staff F, an LPN, worked from 5:00 PM to 5:19 AM the next day, and the schedule again lacked an RN. The facility reported a census of 49 residents on 5/24/26 and 50 residents on 7/5/26, including 3 residents receiving Medicare Skilled services. The DON stated the facility was unable to hire nurses, and the Administrator stated the staffing agency did not notify the facility when an RN called off and that coverage was often obtained at the last minute.
RN Coverage Not Provided for Required Daily Hours
Penalty
Summary
The facility failed to provide the services of a Registered Nurse for eight consecutive hours per day, seven days per week. On 7/4/26, the only RN on duty, V101, clocked in at 10:50 AM and clocked out at 12:59 PM for a total of 2 hours and 9 minutes. On 7/5/26, V101 clocked in at 10:00 AM and clocked out at 11:45 AM for a total of 1 hour and 45 minutes. The Human Resource Director confirmed that V101 was the only RN on duty on those dates, and the Regional Nurse Consultant stated that no agency RNs were used that weekend. The Regional Nurse Consultant also stated the facility did not have a staffing policy and followed state regulations for staffing. Another staff member confirmed there was no Regional Nurse Consultant present because it was a holiday weekend unless there was an emergency. The facility's daily census sheet dated 7/13/26 documented 121 residents in the facility.
Missed RN Coverage on Weekend Shifts
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. Record review of June 2026 Time Sheets and July 2026 Time Sheets showed the facility did not have the required RN coverage on 06/13/26 or 06/14/26. During an interview on 07/27/26 at 1:10 PM, the Director of Nursing stated the staff member who typically provided weekend RN coverage was on vacation on 06/13/26 and 06/14/26, and she was unable to provide coverage that weekend. She stated the facility attempted to obtain coverage from other staff members without success and that the expectation was to maintain at least 8 hours of consecutive RN coverage per day. During an interview on 07/27/26 at 1:40 PM, the Administrator stated the facility did not have a policy on utilizing an RN for 8 hours per day, 7 days per week and deferred to HHSC regulations.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.