Failure to Maintain a Full-Time DON for Required Nursing Leadership Coverage
Penalty
Summary
The deficiency involves the facility’s failure to designate and maintain a full-time (40 hours per week) registered nurse as the Director of Nursing (DON), as required by regulation and the facility’s own policy. Review of DON time clock records from mid-December 2025 through mid-February 2026 showed no evidence of 40 hours of DON coverage for 9 of 11 reviewed weeks. The records reflected only sporadic hours worked by the DON on a few specific days in January and February. At the time of survey entrance on 1/28/2026, the AIT, the owner, and the ADON each stated there was no DON present in the building. The DON later reported that 2/5/2026 was her first day working on the floor in the facility and that she had only completed online training prior to that date. The ADON stated during interview that the facility had not had a DON in the building 40 hours per week since mid-December 2025, that a DON had been hired but had not been in the building full-time, and that RNs working in the facility were not fulfilling DON duties and did not want to serve in the DON role. The ADON further stated that resident care had been affected because there was no Infection Preventionist, no one had conducted antibiotic stewardship, and care plans had not been updated. The AIT confirmed there was no full-time DON and that the newly hired DON had only completed online training and had not started full-time in the facility. The facility’s policy on the Director of Nursing Services, revised August 2006, specified that the DON is employed full-time (40 hours per week) and is responsible for multiple nursing leadership functions, including developing nursing objectives and standards, maintaining policies and procedures, coordinating services, staffing, staff training, participating in MDS and care planning, and ensuring care is provided according to residents’ assessments and care plans.
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