Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
DON Did Not Work Full Time or Perform DON Duties: The facility failed to ensure the DON of record worked 40 hours per week and fulfilled DON responsibilities while repeatedly working as a charge nurse on day and night shifts. Staff reported the DON was pulled to the floor because of staffing shortages, no unit managers were available, and the DON could not complete normal DON and risk management duties while covering open shifts.
Missing Full-Time DON Oversight: The facility failed to ensure an RN was designated to serve as DON on a full-time basis after the DON quit, leaving the nursing department without the required full-time RN oversight. The facility assessment called for a full-time DON, and interviews with the DSD and Administrator confirmed the DON was responsible for overseeing nursing services and coordinating care.
RN coverage was not maintained for eight consecutive hours. Staffing records showed one RN scheduled for 5.25 hours and another RN with administrative duties scheduled for 7.5 hours, while timecards showed no RN worked a full 8-hour consecutive shift. The Administrator confirmed the gap, and the facility policy required RN services for at least 8 consecutive hours each day.
The facility failed to maintain a full-time qualified DON and failed to have RN coverage for 8 hours a day. The Facility Assessment stated that one DON would be staffed, but the Administrator reported there was no DON at the time of survey. A resident council president stated that care seemed to have gone downhill since there had not been a DON, and the facility census showed 79 residents.
RN Coverage Not Maintained for Required Hours: The facility failed to ensure an RN was scheduled for at least 8 consecutive hours a day, 7 days a week. Review of staffing schedules showed multiple days without the required RN coverage, and the DON stated the facility had staffing challenges and was actively hiring. The Administrator stated there was no staffing policy and that CMS guidelines were followed. The census documented 82 residents.
Failure to provide 8 consecutive hrs of RN coverage daily. Review of schedules showed the facility did not have consecutive RN coverage on multiple days, and the Administrator stated the RN had been splitting her day to provide 8 hrs of coverage total rather than 8 consecutive hrs. The facility policy required an RN for at least 8 consecutive hrs a day, 7 days a week, unless waived by state regulations.
DON Did Not Work Full Time or Perform DON Duties
Penalty
Summary
The facility failed to ensure the Director of Nursing (DON) of record worked full time, defined as 40 hours per week, and failed to ensure the DON could fulfill DON duties for 3 weeks from 5/4/2026 to 5/24/2026. Review of DON D’s timesheet for May 2026 showed that during each Monday through Friday work week, DON D was working as a charge nurse on day or night shifts that were anywhere from 7 to 16 hours long, including 4 of 5 days worked during the first week, 3 of 5 days during the second week, and 4 of 5 days during the third week. Multiple interviews confirmed that DON D was routinely pulled to the floor to work as a charge nurse on different shifts, including nights, because the facility did not have enough nurses and no unit managers were available. Staff stated that DON D was not available to perform DON responsibilities while working these shifts, and DON D himself reported that he had to work any open shift and was not necessarily able to do much as a DON or complete risk management duties because he was often working the floor. The DON job description stated that the DON plans, coordinates, and manages the nursing department and is responsible for overall direction, coordination, and evaluation of nursing care and services provided to residents.
Missing Full-Time DON Oversight
Penalty
Summary
The facility failed to ensure that a Registered Nurse was designated to serve as the Director of Nursing on a full-time basis. The facility assessment dated 5/29/26 stated that a DON should be present full time five days per week, and it also identified two Registered Nurse Supervisors. A review of the DON's terminated W-2 dated 6/4/26 showed that the DON's last day of employment was 6/4/26, leaving the facility without a DON in place. During interviews, the Director of Staff Development stated that the DON quit on 6/4/26 and was responsible for overseeing the nursing department, and that not having a DON created a potential for residents' quality of care to be compromised. The Administrator stated that the DON was necessary to coordinate care between staff and residents and that there was a potential for a negative outcome when the facility did not have a DON. The facility policy titled Director of Nursing Services stated that the nursing services department is managed by the DNS, who is an RN employed full-time 40 hours per week, and that the DNS may serve as charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
RN Coverage Not Maintained for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was present for eight consecutive hours in the facility. Review of the daily posted staffing information for 06/06/26 showed one RN scheduled for 5.25 hours and a second RN with administrative duties scheduled for 7.5 hours. Review of RN #354’s timecard showed a shift from 6:40 A.M. to 12:12 P.M., and review of the former RN #513’s handwritten and unsigned timecard showed two separate shifts, from 1:00 A.M. to 2:15 A.M. and from 7:00 P.M. to 11:00 P.M. Further review found no other RNs worked on 06/06/26, and no RN worked for eight consecutive hours. During interview on 06/15/26 at 12:32 P.M., the Administrator verified that there was not an RN working in the facility for eight consecutive hours on 06/06/26. The facility policy, Staffing, last revised 09/19/24, stated the facility would utilize the services of an RN for at least eight consecutive hours a day, seven days per week.
Failure to Maintain Full-Time DON and Required RN Coverage
Penalty
Summary
The facility failed to maintain a full-time qualified Director of Nursing and failed to have a registered nurse on duty 8 hours a day. The Facility Assessment dated 1/6/26 documented that one Director of Nursing would be staffed, and the cited federal regulation requires facilities to designate a full-time RN as the Director of Nursing and to utilize RN services for at least 8 consecutive hours a day, 7 days a week, with limited waivers or exemptions in certain rural areas. During interview on 6/22/26 at 10:30am, the Administrator stated that there was no Director of Nursing at that time. During interview on 6/23/26 at 10:00am, the Resident Council President stated that it seemed like care had gone downhill since there had not been a Director of Nursing. The facility census report dated 6/22/26 documented that 79 residents resided in the facility.
RN Coverage Not Maintained for Required Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. On 6/16/2026, staffing schedules for May and June 2026 were reviewed and showed that the facility did not have at least 8 consecutive hours of RN coverage on multiple dates, including 5/1 through 5/6, 5/11, 5/13 through 5/24, 5/26, 5/29 through 5/31, and 6/1 through 6/4, 6/6, 6/8 through 6/11, and 6/14 through 6/17. On 6/18/2026, the DON stated the facility had challenges with nurses, used a scheduling program, and was actively hiring. The Administrator stated the facility did not have a staffing policy and followed CMS guidelines. The daily census dated 6/14/2026 documented 82 residents in the facility.
Failure to Provide Consecutive RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of RN coverage daily for a census of 37 residents. Review of schedules showed that consecutive RN coverage was not provided on 5/30/26, 5/31/26, 6/6/26, and 6/13/26. During an interview on 6/18/26 at 9:55 AM, the Administrator stated she did not realize the RN coverage had to be eight consecutive hours and explained that the facility had an RN dividing up her day to provide eight hours of RN coverage total each day. The Nursing Services Staff policy revised 10/14/25 stated that the location would use the services of an RN for at least eight consecutive hours a day, seven days a week, except when waived by state regulations.
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