Failure to Provide Required RN Coverage or DON Charge Nurse Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for at least 8 consecutive hours in a 24-hour period, and the DON did not serve as charge nurse as permitted when census is 60 or fewer residents. Review of the daily staff posting, daily assignment sheet, and time cards for May 26, 2025, showed that no RN was scheduled or worked on either the day shift (6:00 AM to 6:30 PM) or the night shift (6:00 PM to 6:30 AM). Instead, two LPNs were scheduled and worked on the day shift, and two LPNs were scheduled and worked on the night shift, with no documentation of RN presence or coverage for that date. During interviews, the DON confirmed that there was no RN scheduled to work for 8 consecutive hours on that date and acknowledged that facility expectations are to have an RN scheduled and on shift to delegate care and oversee LPNs and nursing aides. The DON initially stated she could serve as charge nurse due to the facility’s bed occupancy but later confirmed she did not serve as charge nurse on May 26, 2025, so no hours could be counted toward the RN coverage requirement. The Administrator and CEO also confirmed that the expectation is to have RN coverage for a consecutive 8 hours, 7 days a week, and that the DON did not function as charge nurse on that date. Review of the facility assessment, last updated October 24, 2025, showed it listed nursing roles such as DON, RN, LPN, CNA, medication technician, wound nurse, and MDS nurse as needed resources but did not specify staffing expectations for RN coverage.
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