Failure to Maintain Required RN Coverage and Full-Time RN DON
Summary
The deficiency involves the facility’s failure to provide required RN coverage for at least eight continuous hours daily and to employ a full-time RN as the DON. Surveyors observed the posted daily staffing sheets on three separate days and found no RN hours documented. Review of the facility’s Payroll Based Journal (PBJ) staffing data for FY Q4 2025 showed multiple dates across July, August, and September with no recorded RN hours. The facility’s own undated Registered Nurse policy stated that an RN would be employed for at least eight consecutive hours, seven days per week, but the documented staffing patterns did not reflect this requirement. Administrative staff confirmed that the facility had not had an RN serving in the DON role since 2023 and that the individual currently functioning as DON was an LPN enrolled in an RN program, with an anticipated completion date in the future. Administrative staff also confirmed the accuracy of the PBJ report for dates with no RN coverage and declined to review those dates with the survey team. They reported that the facility did not provide skilled services, stating those were provided by a neighboring hospital, and that the facility was actively but unsuccessfully recruiting RNs. The job description for the DON provided to surveyors did not specify that the DON must hold an active, unencumbered RN license, further evidencing the lack of a full-time RN in the DON role as required.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
RN Coverage Not Maintained: The facility failed to provide RN services for at least 8 consecutive hours per day on 2 days reviewed. RN time punches showed no RN hours, and the ADM, DON, and staffing coordinator confirmed there was no RN coverage when the scheduled RN called off sick and no replacement was found. The facility policy stated an RN provides services at least 8 hours every 24 hours, 7 days a week.
The facility failed to maintain a full-time RN serving as DON, resulting in two distinct periods with no designated DON in place. After the prior DON left, a new DON was briefly hired but soon resigned for health reasons, leaving the position vacant again until another RN was promoted to DON. During these gaps, two ADONs attempted to oversee resident care. The Administrator acknowledged the absence of a DON, confirmed reliance on ADONs, and stated that the facility lacked a specific DON policy and was following state regulations, while recognizing that lack of DON oversight could affect nursing supervision, resident documentation, and response to changes in condition.
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.
The facility failed to designate a full-time DON and did not clearly assign or document DON responsibilities, despite having RNs providing coverage. Time records and posted schedules showed no RN identified as DON over several weeks, and one RN listed as interim DON on the administrative roster stated she was only assisting as agency staff and did not function as DON. The Owner believed this RN was acting as interim DON based on information from the Administrator, while the Administrator later acknowledged that no RN had actually been designated as DON and cited difficulty filling the position after the previous DON’s death, recognizing this could lead to incomplete resident assessments.
The facility failed to provide RN coverage for 8 consecutive hours daily and failed to maintain a full-time RN DON. Payroll review showed multiple days with no RN services, and interviews confirmed gaps in DON coverage after successive resignations. The HR Director, ADON, and Administrator all acknowledged periods when neither an RN nor a DON was present, while the facility continued interviewing for the DON role.
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.
RN Coverage Not Maintained
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 for 2 of 30 days reviewed for RN coverage. Record review of RN time punches provided by the facility showed no RN hours for 4/24/2026 and 4/25/2026, and the facility failed to maintain RN coverage of eight hours on those dates. During interviews on 5/06/2026, the ADM stated there was no RN coverage for those two days and explained that the staffing coordinator and the DON were responsible for scheduling RN coverage. The DON stated the RN scheduled for that weekend called off sick and a replacement could not be found, and that agency was used for LVN nurses only, not RN coverage. The staffing coordinator stated she did not look for a replacement and believed the DON would do so because the RN had called in to the DON. The facility policy titled, Staffing, Sufficient and Competent Nursing, revised 08/22, stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week.
Failure to Maintain a Full-Time DON Position
Penalty
Summary
The deficiency involves the facility’s failure to designate and employ a full-time registered nurse (RN) as the Director of Nursing (DON) as required by federal regulation 483.35(b)(2). Record review showed that the prior DON’s (DON E) last day worked was 03/03/2026, and the HR Coordinator confirmed his last day of employment as 03/04/2026. A job offer was extended to another RN (DON F) with a start date of 03/18/2026, but payroll records indicated that this DON resigned for health reasons with a termination date of 03/31/2026. A subsequent job offer was extended to another RN (DON D) with an effective date of 04/20/2026. During the surveyor’s on-site investigation on 04/29/2026, DON D was not present at the facility and was reported by the Administrator to be at a sister facility for training. Interviews with the Administrator and DON D confirmed that there was no DON in place from 03/04/2026 through 03/17/2026 and again from 04/01/2026 through 04/19/2026. During these gaps, the facility relied on two Assistant Directors of Nursing (ADONs) to assist with overseeing residents and to compensate for the lack of a DON. The Administrator acknowledged that the facility did not have a DON for the identified periods and stated that the facility had advertised for the position but was seeking candidates with nursing facility experience. The Administrator also stated there were possible barriers for residents when there is no DON, including lack of supervision over nursing staff, issues with residents’ documentation, and potential problems if residents experienced a change in condition. The Administrator further stated that the facility did not have a specific policy for the DON requirement and followed state regulations instead.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
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.
Failure to Designate a Full-Time DON and Ensure RN Leadership Coverage
Penalty
Summary
The deficiency involves the facility’s failure to designate a full-time Director of Nursing (DON) who is a registered nurse, and to ensure that this role was clearly assigned and documented. Review of clock-in/clock-out reports from mid to late April 2026 showed no evidence of any RN designated as DON for three consecutive weeks. An observation of the posted staffing schedule on April 30, 2026, showed 12-hour nursing shifts listed but no RN scheduled for that date. The facility’s own DON job description outlined extensive responsibilities for planning, organizing, and directing clinical services, but there was no individual formally identified and functioning in that role on a full-time basis during the reviewed period. In interviews, an RN who had been assisting the facility stated she was not the designated DON, despite being listed as interim DON on the administrative staff roster. She reported that she had been working both remotely and on-site, including full weekends, and had worked 40 hours per week for the facility in recent weeks, but only as agency staff providing RN coverage, not as DON. She emphasized that she did not consider herself the DON because the position carried greater responsibility, and she intended to speak with the Administrator to clarify her role. Another RN reported that the facility was supposed to have DON coverage and that she had been assisting with RN coverage in the absence of a DON. The Owner stated he believed, based on information from the Administrator, that the assisting RN was serving as the interim DON, and he also stated the facility had been providing eight hours of RN coverage. When informed that the RN did not consider herself the DON, he acknowledged that something could fall through the cracks without a full-time DON. The Administrator later confirmed that RN A should not have been classified as interim DON and that neither of the two RNs providing eight hours of daily coverage had been designated as DON. The Administrator reported difficulty hiring a full-time DON following the death of the previous DON at the end of February and acknowledged that the lack of a DON could lead to incomplete resident assessments.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to utilize the services of an RN for 8 consecutive hours a day, 7 days a week, and failed to designate an RN as the DON on a full-time basis. Review of RN payroll hours for 01/01/26 through 04/29/26 showed no RN services on 20 dates in January, February, March, and April 2026. The facility also had periods without a DON after the prior DON resigned on 02/18/26, with the HR Director stating there were 6 days in February without a DON, 16 days in March without a DON after another DON resigned on 03/04/26, and 8 days in April without a DON after the next DON resigned on 04/20/26. During interview, the HR Director stated the facility had not hired a full-time DON after the resignations and that the Administrator was responsible for ensuring daily RN coverage and hiring a DON. The HR Director said the facility had been interviewing candidates but had not hired anyone. The ADON, who is an LVN, stated that at times there was neither an RN nor a DON present and that she would seek guidance from a DON at another facility, physicians, Nurse Practitioner, pharmacy, or dietitian when needed. She also stated that having an RN and DON was important because they provided oversight, guidance, and more in-depth assessment when needed. The Administrator acknowledged that the facility did not have RN coverage or an acting DON and stated he expected the facility to have an RN working eight consecutive hours every day and to have an acting or full-time DON. He said the previous DON resigned without notice, the facility had been advertising for the DON position, and there was no corporate RN or regional RN to assist until one was hired. Record review of incidents and accidents for January through April 2026 did not reveal any negative outcomes related to the lack of RN services or DON coverage. The facility policy stated the Nursing Services department is under the direct supervision of an RN and that the DON is a registered nurse employed full-time 40 hours per week.
RN Not Scheduled 8 Hours Daily and 7 Days Weekly
Penalty
Summary
The facility failed to ensure that the services of a registered nurse (RN) were provided for at least eight consecutive hours a day, seven days a week. During an interview, an LVN stated there were times when an RN was not available and that there were only about two or three full-time RN staff overall in the facility. The DSD stated the facility did not consecutively have an RN scheduled for eight consecutive hours a day, seven days a week, and that although there were three full-time RNs, they were not always available on weekends. During record review, the facility's Skilled Nursing-Per Patient Day report for August 7, 2025, through August 31, 2025, showed no RNs listed on August 7, August 10, August 11, August 23, August 24, August 30, and August 31. The DSD confirmed the facility did not schedule an RN seven days a week during that period. The DON stated the facility had difficulty finding RN coverage consistently as required by federal regulations and that the facility did not have a policy addressing RN staffing.
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