Failure to Maintain Required RN Coverage and Full-Time RN DON
Penalty
Summary
The deficiency involves the facility’s failure to provide required RN coverage for at least eight continuous hours daily and to employ a full-time RN as the DON. Surveyors observed the posted daily staffing sheets on three separate days and found no RN hours documented. Review of the facility’s Payroll Based Journal (PBJ) staffing data for FY Q4 2025 showed multiple dates across July, August, and September with no recorded RN hours. The facility’s own undated Registered Nurse policy stated that an RN would be employed for at least eight consecutive hours, seven days per week, but the documented staffing patterns did not reflect this requirement. Administrative staff confirmed that the facility had not had an RN serving in the DON role since 2023 and that the individual currently functioning as DON was an LPN enrolled in an RN program, with an anticipated completion date in the future. Administrative staff also confirmed the accuracy of the PBJ report for dates with no RN coverage and declined to review those dates with the survey team. They reported that the facility did not provide skilled services, stating those were provided by a neighboring hospital, and that the facility was actively but unsuccessfully recruiting RNs. The job description for the DON provided to surveyors did not specify that the DON must hold an active, unencumbered RN license, further evidencing the lack of a full-time RN in the DON role as required.
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