Failure of Administration to Ensure DON, RN Coverage, Scope Compliance, and Adequate Staffing
Penalty
Summary
The deficiency involves the Administrator’s failure to ensure appropriate nursing leadership, RN coverage, and staffing, as required by the Administrator job description and federal regulations. The Administrator’s job description states they are responsible for directing day-to-day facility functions in accordance with applicable regulations, recruiting competent department directors, and ensuring adequate trained licensed and non-licensed personnel are on duty at all times. Despite this, the facility had no Director of Nursing (DON) after the last DON’s final day on 03/13/26, which was confirmed by both the Administrator and the Regional Director of Operations (RDO). The RDO reported that DONs from sister facilities were helping, but there was no documented evidence of their presence. The Assistant Director of Nursing (ADON) confirmed the facility had not had an RN on staff since the former DON left on 03/13/26 and that, even when the former DON was present, there was no RN coverage for most weekends. Surveyors determined that Administration was aware there was no qualified DON overseeing resident care since 03/13/26 and that there was not an RN in the building for a minimum of 8 hours a day, 7 days a week. The facility also failed to ensure that staff worked within their scope of practice and that staffing levels were sufficient to meet residents’ needs. Clinical record review for one resident (R2) showed that a Certified Medication Aide/Medication Technician (CMA/MT1) assessed pain levels, administered PRN narcotic pain medications, and reassessed pain, and CMA/MT1 confirmed she had been performing these assessments and administering PRN narcotics throughout her employment. The Vice President of Clinical Operations stated that it was not within a CMA/MT’s scope of practice to assess pain or administer PRN pain medications. A local police narrative documented that the Administrator told an officer that one resident needed constant care and that it was very difficult to provide that level of care due to lack of staffing. One resident reported that call lights took 30–45 minutes to be answered, another resident reported that during mealtimes all staff went to the dining room leaving no staff on the halls, and an LPN stated residents needed more attention than staff could provide. The survey identified these failures under F727 (nursing services and RN/DON requirements), F658 (services within scope of practice), and F725 (sufficient staffing), and Immediate Jeopardy was cited under §483.35 Nursing Services related to facility administration.
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