DON Inappropriately Used as Charge Nurse When Census Exceeded 60
Penalty
Summary
The deficiency involves the facility’s failure to prevent the Director of Nursing (DON) from serving as a charge nurse despite a reported census of 124 residents, which exceeds the regulatory threshold of 60 residents. Multiple staff interviews on 02/12/2026 confirmed that the facility was understaffed and that the DON had been working nights and overnight shifts on the floor in a charge nurse role to cover staffing shortages. Staff P, an RN, stated the facility was understaffed and that the DON was serving as a charge nurse. Staff Q, an RN, reported that the DON had been working as a charge nurse alongside the Assistant Executive Director and other nursing leadership to address staffing shortfalls and that the DON was working the floor the week she left for maternity leave. Additional staff corroborated that the DON had been functioning as a floor nurse. Staff R, a CNA, confirmed the DON had been working the floor as a nurse leading up to her maternity leave due to staffing shortages. Staff L, a CNA, similarly confirmed that the DON was working the floor in a nurse leadership capacity and stated this last occurred in January. Review of the last 30 days of staffing logs showed the DON worked as a floor nurse on 01/11/2026 and 01/21/2026. In an interview, the Assistant Executive Director confirmed the DON had been serving as a charge nurse on the floor and acknowledged awareness that this was prohibited. A policy addressing this issue was unavailable for review.
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