Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Maintain Required RN Coverage: The facility did not have an RN in the building for at least 8 consecutive hours a day, 7 days a week on multiple dates. Administrative Nurse D verified that no RN was present for the required coverage or serving as charge nurse on those dates, despite the facility policy requiring daily RN coverage and a full-time DON.
Failure to Maintain Required RN Coverage: The facility failed to ensure an RN was on duty for at least 8 consecutive hours a day, 7 days a week on multiple reviewed days. Daily HR reports showed zero RN hours worked on several dates, and both the DON and ADM stated they could not explain why RN coverage was absent, while acknowledging the requirement for daily RN coverage and the administrator's responsibility for staffing.
RN and DON Coverage Not Maintained: The facility failed to ensure an RN served as DON on a full-time basis and failed to maintain RN coverage for at least eight consecutive hours each day. Staffing schedules, timecards, and staff interviews showed no RN worked on two days and no DON was present for several days. Interviews also confirmed the DON coverage was intermittent, with one RN serving only on limited days and another stating she had no documentation showing she worked in the facility after the prior DON left.
Lack of Documented Daily RN Coverage: Surveyors found that the facility did not have documented RN coverage scheduled for at least 8 consecutive hours per day, 7 days a week. Review of staffing postings showed multiple days without the required RN coverage, and the ANHA stated there were no other documents available to verify RN coverage. No policy was provided by the end of the survey.
RN Coverage Not Maintained: The facility failed to ensure RN services for at least 8 consecutive hours per day, 7 days a week. Time records showed missing RN coverage on multiple days, and the DON and ADM acknowledged that RN staffing hours were absent at times. The facility policy required RN coverage and allowed DON hours to count toward the requirement.
RN Coverage Not Maintained as Required: The facility failed to maintain RN coverage for at least 8 consecutive hours per day. Record review showed multiple days with no RN in the building within a 24-hour period and other days with less than 8 consecutive hours of RN coverage. Interviews confirmed the Staffing Coordinator and DON leadership understood the coverage expectation differently, and the facility sometimes relied on an on-call RN to come in if issues arose.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Review of the Registered Nursing Staffing Schedule for March 2026, April 2026, and May 2026 showed the facility lacked an RN on 03/16/26, 03/21/26, 03/22/26, 04/04/26, 04/18/26, 05/02/26, 05/03/26, 05/16/26, 05/23/26, 05/24/26, and 05/31/26. On 06/03/26 at 09:00 AM, Administrative Nurse D verified that the facility did not have an RN in the building for eight consecutive hours or working as a charge nurse on those dates. The facility's RN policy, dated January 2024, stated the facility would employ an RN for at least eight consecutive hours a day, seven days a week and would designate an RN to serve as the DON on a full-time basis, with the DON serving as charge nurse only when the average daily census was 60 or fewer residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week on 10 of 15 days reviewed for RN coverage. Review of the daily HR total employee hours reports provided by the ADM showed zero RN hours worked on 10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25, and 12/28/25. The report stated the facility failed to ensure RN coverage on those dates and that this could place residents at risk of missed nursing assessments, interventions, care, and treatment. During interview, the DON stated she was not the DON during the dates with no RN coverage and could not explain why there was no RN coverage because she started in February 2026. She stated the facility was required to have 8 consecutive hours every day, 7 days a week of RN coverage and that being without an RN was unacceptable. During interview, the ADM stated he did not know why there were no RN hours on the listed dates because he started as administrator in March 2026, but acknowledged the expectation of at least 8 RN hours daily and stated it was ultimately the administrator's responsibility to ensure staffing coverage. He also stated he could not find documentation showing an RN was in the facility for the required 8 hours and that there was no facility policy specific to RN hours, only state and federal guidelines.
RN and DON Coverage Not Maintained
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was designated as the Director of Nursing (DON) on a full-time basis and failed to ensure an RN was working in the facility at least eight consecutive hours per day, seven days a week. Review of staffing schedules and timecard reports for 05/03/26 through 05/09/26 showed that an RN did not work on 05/07/26 and 05/08/26. Review of the same records also showed that a DON was not present in the facility from 05/05/26 through 05/09/26. During interviews, LPN #55 stated the facility did not currently have a DON and described RN, DON #82 as coming every Wednesday to serve as both DON and RN, while RN, DON #84 came two days a week to serve as DON. RN #79 stated she was unaware of how often RN, DON #84 was in the facility. RN, DON #84 stated she was the Regional Nurse, did not punch a clock, and had no documentation showing she had worked in the facility since the previous DON left on 04/29/26. RN, DON #82 stated she did not work in the facility at all from 05/03/26 to 05/09/26, and RN, DON #83 stated she only worked on 05/04/26. The DOO verified that RN, DON #83 was only in the facility on 05/04/26, that RN, DON #82 was only in the building on 05/13/26 and 05/20/26, and that there was no DON coverage in the facility from 05/05/26 through 05/09/26. The DOO also verified there was no RN in the facility on 05/07/26 and 05/08/26 as required.
Lack of Documented Daily RN Coverage
Penalty
Summary
The facility failed to have documented RN coverage scheduled for at least eight consecutive hours per day, seven days a week. During the Staffing Task of the survey, surveyors requested six months of Daily Staffing Census/Postings, and the postings provided showed multiple dates without eight consecutive hours of RN coverage, including 3/5, 3/6, 3/7, 3/8, 3/28, 3/29, 3/31, 4/14, 4/21, 4/24, and 4/28/2026. On 5/21/2026 at 3:12 PM, the Acting Nursing Home Administrator stated there were no other documents available to review for RN coverage. The facility did not provide a policy addressing the concern by the end of the survey.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. Record review of the resident roster dated 05/18/2026 showed a census of 54 residents. Record review of the facility's time detail from April 2026 to May 2026 showed the facility did not have an RN working for a total of 8 hours on 04/11/2026, 04/12/2026, and 05/10/2026. During interview, the DON stated there were days when 8 hours of RN staffing hours were missing and said RN staff were important because they provided a supervisory role to LVNs and CNAs. The ADM also stated it was important to have an RN work 8 hours per day because of the additional training an RN received and said the facility was in the process of hiring more RNs. Record review of the facility's policy, Nursing Services-Registered Nurse (RN), revised 02/2026, reflected the facility would utilize the services of an RN for at least 8 consecutive hours per day, 7 days per week, and that the hours worked by the DON would count toward the requirement.
RN Coverage Not Maintained as Required
Penalty
Summary
The facility failed to use the services of a registered nurse for at least eight consecutive hours per day, seven days per week. Review of Employee Paired Punches from 12/01/2025 to 05/05/2026 showed no registered nurse in the building within a 24-hour period on 12/15/2025, 12/16/2025, and 12/18/2025, and less than eight consecutive hours of registered nurse coverage on 12/17/2025 and 02/24/2026. During interviews, the Staffing Coordinator stated that a registered nurse had to be in the building for at least eight hours per day, but the hours did not have to be consecutive. The Regional Director of Nursing stated they were aware that there had to be a registered nurse in the building for eight out of 24 hours, were aware there were times with no registered nurse in the building, and that the facility occasionally used an on-call registered nurse who would come in if there were issues. The Administrator stated they were not aware of the lack of registered nurse coverage.
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