F0835

L

Failure to Verify DON Licensure Resulting in Unlicensed Nursing Leadership

Greenville, South Carolina Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to have systems in place to verify licensure for nursing leadership, specifically the Director of Nursing (DON). The South Carolina Department of Labor, Licensing and Regulation issued an order dated June 18, 2025, temporarily suspending the DON’s nursing license effective immediately. Despite this suspension, the DON continued in her role, which, per her signed job description dated May 15, 2024, included overseeing and supervising the care of all residents, providing direct resident care as needed, managing the entire nursing department and staffing levels, ensuring resident safety, and supervising the ADON and all nursing staff. The job description also required that the DON be in good standing with the State Board of Nursing and maintain all required licensure requirements at all times.

Human resources staff reported in interview that the DON was terminated on June 25, 2025, for conduct and unprofessionalism related to sexual harassment, and that they were unaware of the license suspension at the time of termination. HR stated that the DON was a salaried exempt employee who did not clock in and out, and HR could not specify what duties the DON performed while her license was suspended. Another DON, who assumed the DON role on June 25, 2025, stated that the previous DON would have performed typical DON duties and did not believe she was signed off for any patient care during the suspension period, but also indicated that they did not learn of the suspension until June 30, 2025, after conducting an internal audit prompted by information the former DON shared following her termination.

During interviews, HR staff acknowledged that the facility did not have a policy for auditing licenses and that, for nurses, licenses were not checked between the two‑year renewal periods unless there was a specific reason to do so. The facility stated that licensure verification was performed at hire, at licensure renewal dates, and annually, but no verification occurred in the seven days between the Board’s temporary suspension order and the DON’s termination. The State Agency determined on February 14, 2026, that the facility’s non‑compliance with federal regulations related to administration could cause psychosocial harm, and Immediate Jeopardy was cited under 42 CFR §483.70, with the IJ determined to have existed as of June 18, 2025, due to the DON continuing to provide clinical oversight, supervise nursing staff, and provide direct resident care while unlicensed.

Removal Plan

• The Director of Nursing notified the Medical Director of the Immediate Jeopardy and will complete any additional required external notifications if applicable.
• The Human Resource Director initiated a primary source audit of all currently employed licensed nursing staff to confirm active licensure and good standing; no issues were identified.
• Verification evidence for all licensed nursing staff was printed or electronically saved and will be placed into appropriate personnel files.
• The Director of Nursing completed a look-back investigation for all shifts worked by the former Director of Nursing; the review found no evidence of resident harm or complaints, and residents were interviewed/assessed with no complaints or negative effects identified.
• Licensed nursing staff received mandatory re-education to immediately notify the Administrator and/or Director of Nursing if their license is under investigation, a licensure-related consent order is entered, or the license becomes suspended, restricted, expires, or changes status for any reason.
• The Human Resource Director will audit nursing licenses monthly for 3 months and then quarterly for 3 quarters; results will be reported to the QAPI Committee monthly for 3 months and quarterly for 3 quarters, with the QAPI Committee re-evaluating the need for further monitoring after these periods; the Human Resource Director will be responsible for monitoring and follow up.
• The Human Resource Director uploaded current, active nursing licenses for all licensed nursing staff into the facility's human resources system to ensure centralized and accessible credential verification.
• The Human Resource Director was re-educated by the Regional President and Assistant Regional Director of Clinical Services on the licensure certification and registration of personnel policy.
• The facility implemented a process requiring all newly hired employees to sign an attestation that they must inform the Administrator, Director of Nursing, or Human Resource Director of any licensure investigation, licensure-related consent order, or change in licensure status; failure to report is grounds for discipline up to and including termination.
• The facility initiated an attestation for all currently employed licensed personnel that they must inform the Administrator, Director of Nursing, or Human Resource Director of any licensure investigation, licensure-related consent order, or change in licensure status; failure to report is grounds for discipline up to and including termination.
• All attestations for licensed personnel will be completed or the employee will not work until the attestation is completed.
• A standardized license verification form and central licensure tracking log with verification and expiration dates will be implemented.