Failure to provide required RN coverage: The facility did not have an RN scheduled for at least 8 consecutive hours a day, 7 days a week as required by policy. Review of the staffing schedule showed multiple AM and PM shifts with no RN assigned, while the DON and ADM stated RNs were needed for rounds and had a broader scope of practice than LVNs. The facility had 62 residents at the time of review and a licensed capacity of 101 beds.
Failure to Maintain Required RN Coverage: The facility did not have an RN on duty for the required eight consecutive hours every day. The DON stated the RN went on medical leave, no additional RNs were hired, and there were no RNs working weekends. Staffing calendars showed multiple days in which no RN was scheduled, and the Administrator stated the facility relied on an on-call RN list for residents with IV medications and that the DON had to come in after hours for coverage.
Lack of DON Coverage: The facility failed to have a DON for more than 5 months. The person identified as FDON stated they were not the designated DON and only assisted with RN duties, while HR confirmed they were hired full time as DON at another facility. The Administrator stated the facility had no DON, had been trying to hire one, and no DON job posting was listed on the careers page. A facility coverage log showed no DON starting from 3/15/2025.
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.
No RN on duty for required shifts. Facility records showed that an RN was not on duty for any of the three shifts, and the nursing assignment sheet confirmed there was no RN present for 8 consecutive hours. The DSD and DON both confirmed the staffing gap, and the DON stated the facility did not have a policy and procedure on RN staffing. The Nurse Supervisor job description stated that sufficient LPNs and/or RNs are to be available to maintain quality care.
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
RN staffing was not provided for at least 8 consecutive hours a day, 7 days a week. An LVN stated there were times when no RN was available, and the DSD confirmed the facility did not consistently schedule an RN every day, including weekends. Record review showed multiple days with no RN listed on the staffing report, and the DON stated the facility had difficulty maintaining RN coverage and had no policy addressing RN staffing.
The facility failed to follow its staffing policy when no RN was present for the required 8 consecutive hours in a 24-hour period. Review of TSNH records showed multiple days with 0 RN hours despite resident census levels of 52 to 55, and the DON and ADON confirmed the RN was not covering the floor on those dates.
The facility failed to ensure an RN was on duty for 8 consecutive hours a day, 7 days a week. Review of staffing sign-in sheets showed no RN available for a consecutive 8-hour shift on multiple dates, and the DSD confirmed there was no RN present in the building for 8 hours on those days. The facility policy stated that F727 requires an RN onsite at least 8 consecutive hours daily.
The facility failed to ensure an RN was on duty for 8 hours a day, 7 days a week. During record review with the DSD, the clock-in log showed multiple days when no RN was present in the building for the required 8 hours, despite the facility policy stating an RN must provide services at least 8 consecutive hours every 24 hours.
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