DON Used as Floor Nurse When Census Exceeded 60 Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure the DON was not used as a floor/charge nurse when the facility census exceeded 60 residents, as required. Census records from early November through early January showed multiple days when the resident census ranged from 72 to 82. Staffing logs for the same period documented that on several of those days with a census above 60, the DON was scheduled and worked on the floor as a nurse/charge nurse, including full and partial shifts on multiple dates. During an interview, the DON confirmed she had worked the floor on the identified dates because there was not enough nurse coverage and stated that when she works as a floor or charge nurse, it is difficult for her to complete her other DON responsibilities. She also reported having recently lost three agency nurses and that the facility was in the process of obtaining new agency contracts. The facility census at the time of the survey was 72 residents, and the surveyors concluded that this practice was likely to affect all 72 residents in the facility.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.