Failure to Maintain a Qualified Full-Time DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the full-time Director of Nursing (DON) and did not have a qualified full-time or interim DON from 12/27/2025 through 02/19/2026. Interview and record review showed that the previous DON’s last day was 12/27/2025, and the Administrator reported that an RNC was acting as the interim DON, overseeing the facility and being readily available by phone as needed. However, the Administrator acknowledged that the RNC did not qualify as an interim DON because the RNC was not in the facility 8 hours a day, as required. The Administrator also stated that the facility did not have a policy outlining DON requirements and instead relied on state regulations for guidance, and believed residents had not experienced negative outcomes because the RNC had been overseeing the facility and nursing staff were available. The surveyors determined that this failure could place all residents at risk of not receiving necessary care and services. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency was identified at the facility level based on staffing and leadership requirements for nursing services.
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