Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to employ and have an actively working full-time Director of Nursing (DON). Review of staff clock-in times and resident records showed no documentation of an RN being in the building for eight consecutive hours on 02/21/26 or 03/08/26. The facility assessment dated 01/30/26 stated the facility must have a full-time DON, full-time Assistant DON (ADON), full-time wound care nurse, and full-time MDS nurse, but these positions were not filled or actively working in the facility during the survey period. Multiple staff interviews confirmed the absence of key nursing leadership and RN coverage. CNAs reported there was no DON, ADON, MDS nurse, or wound care nurse in the facility and that there was no nursing management available to report issues or concerns to. Human resources staff stated the previous DON gave a 30‑day notice but stopped working before the end of the notice period, and the ADON resigned effective immediately, leaving those positions vacant; positions for MDS nurse, wound care nurse, and ADON remained open. An LPN reported the facility was short on RN hours, that RNs were scheduled but often did not show up or quit, and that the situation worsened without a DON or ADON in the building. Other staff confirmed the facility was not meeting required RN hours, that RN names were placed on schedules and PPD sheets without the individuals being physically present, and that no corporate nurses came in to fill in for the DON or ADON.
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