Failure to Provide Required Daily RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide a registered nurse (RN) on duty for eight consecutive hours daily as required, affecting all 104 residents. The administrator reported that the facility does not have a stand-alone staffing policy and instead follows minimum nurse staffing guidelines, including RN coverage, and provided staffing sheets showing nurses work 12-hour shifts. Review of these staffing sheets showed that on multiple specific dates (1/3/26, 1/4/26, 1/17/26, 1/18/26, 1/31/26, and 2/1/26), there was no RN scheduled or available in the facility. The former DON stated that their last day of employment was 1/30/26 and confirmed that the facility did not always have an RN available, particularly on weekends, and that while agency nurses were used to cover open shifts, agency RNs were not always available to fill those shifts. The Long-Term Care Facility Application for Medicare and Medicaid dated 2/08/26 documented that 104 residents resided in the facility at the time of the survey, and the lack of RN coverage on the identified dates occurred despite this census.
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