Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the presence of a full-time Director of Nursing (DON) to manage and oversee nursing services, as required by policy. During a complaint investigation, the Administrator confirmed that there was no DON in place and that the Quality Assurance (QA) nurse would provide assistance during the investigation. Multiple staff interviews, including with a licensed nurse and the Director of Staff Development (DSD), confirmed that the facility did not have a full-time DON at the time. The QA nurse, who was the former DON, stated that the facility was still in the process of hiring a new DON and that a consultant was available but not present during the initial investigation. A review of the facility's policy indicated that the DON is required to be employed full-time (40 hours per week) and is responsible for developing and updating nursing service objectives and overseeing standards of nursing practice. The absence of a full-time DON meant that there was no designated individual to oversee clinical care, care planning, and coordination for the safety and well-being of the facility's 188 residents. This lack of leadership and oversight was directly observed and confirmed through staff interviews and record review.