Failure to Maintain Required RN Coverage Seven Days a Week
Penalty
Summary
The facility failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week for multiple days within a 12‑month review period. Review of CMS PBJ staffing data for fiscal quarters 1 and 2 showed no RN coverage on five specific dates. Timecard reports for the same months, provided by the DON, confirmed there was either no RN coverage or not a full 8 hours of RN coverage on those dates. The DON verbally confirmed the lack of RN coverage or full 8 hours of RN coverage on each of the identified days. During an interview, the DON stated her understanding that facility policy required an RN to be on staff 8 hours a day and acknowledged that the facility had difficulty finding RNs, stating they tried their best but were not always successful. She reported that she started working at the facility in November 2025 and indicated she would respond by phone and come in if called when an RN‑level assessment was needed. The facility’s written policy stated that a registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week, which was not met on the identified dates.
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