Failure to Maintain a Full-Time RN Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) who is a Registered Nurse (RN), as required by regulation and the facility’s own job description. The facility assessment tool dated 1/6/26 identified an individual (V9) as the DON and stated that a DON would provide resources needed to support competent care for the resident population every day and during emergencies, and that the Administrator’s team members included the DON. The resident census roster dated 3/6/26 showed 78 residents residing in the facility. Review of V9’s employee file showed a start date of 12/22/25 and a termination date of 1/26/26, and the facility’s DON job description dated 7/2023 required that the DON be an RN with a current, unencumbered state license and direct the overall operation of the nursing department in accordance with state and federal standards. On 3/8/26, during surveyor review, the Administrator (V1) was unable to provide a DON license and stated that the facility required a full-time DON but had not had one since V9’s termination on 1/26/26. V1 further stated that there was no RN serving as DON and that the Assistant Director of Nursing (V2), who was functioning as the acting DON, was only an LPN. Verification of V2’s professional license on 3/8/26 confirmed that V2 held an active LPN license, not an RN license. As a result, the facility did not have a full-time RN serving as DON for the period following 1/26/26, despite having 78 residents in care.
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.