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
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The facility did not maintain required RN coverage for at least eight consecutive hours per day, seven days a week. Review of staffing schedules and the staffing tool, confirmed by interviews with the administrator, HR staff, and the scheduler, showed that on two separate days there was no RN on duty for the required duration, potentially affecting all 50 residents. The facility assessment stated that two RNs and/or LPNs would be scheduled for each shift but did not address the specific requirement for daily eight-hour RN presence, contributing to the deficiency cited under multiple complaint investigations.
The facility failed to employ a full-time RN DON to provide direct oversight of nursing services for all residents. After the prior DON was terminated, an interim DON who also worked at another building was only present one to two days per week, while an ADON who was an LPN handled day-to-day issues and a clinical RN worked weekday shifts but did not function as DON. Staff interviews consistently confirmed the absence of a full-time DON and reliance on the LPN ADON for leadership. The administrator acknowledged there was no full-time DON and that there were no job descriptions for the DON or ADON, and the facility assessment did not list a DON among those completing it, despite identifying the DON as a required member of the IDT and necessary staff classification.
The facility failed to maintain the required continuous 8-hour daily RN coverage when the DON left the building to accompany a resident to outpatient surgical procedures, leaving only LPNs on duty for resident care. Staffing records showed no RN worked in the facility on one of the days in question, despite schedules indicating the DON was present, and the DON later confirmed she was away from the facility for much of the day and not present for eight consecutive hours. Interviews with the resident, the transportation coordinator, the DON, the administrator, and a regional RN corroborated that the DON twice accompanied the resident to a surgical center in another city, that her time in the facility that day was brief, and that the staffing documentation inaccurately reflected her hours, resulting in a day without the required RN coverage for all residents.
The facility failed to ensure an RN was on duty for at least 8 consecutive hours per day, 7 days per week. Record review showed there was no RN coverage on one day, and the COO confirmed the RN was not on duty in the facility. The staffing policy stated the facility should maintain adequate staffing on each shift to meet residents' needs and services.
The facility failed to maintain required RN coverage for at least eight consecutive hours daily and did not have a full-time DON actively working on site. Staff time records showed days with no documented continuous RN presence, despite the facility’s own assessment requiring a full-time DON, ADON, wound care nurse, and MDS nurse. CNAs and other staff reported there was no nursing management (DON, ADON, MDS, or wound care nurse) in the building, no one to report concerns to, and poor communication, including new admissions arriving without notice. Human resources confirmed the prior DON left before completing a notice period, the ADON resigned immediately, and key nursing positions remained vacant, while an LPN and other staff stated that RNs were listed on schedules and PPD sheets but often were not physically present.
The facility failed to provide required RN coverage for at least eight consecutive hours per day, seven days a week, as shown by staffing schedules and timecard punches indicating no RN on duty on two days during a reviewed period, while 97 residents were present on each of those days. The DON confirmed in an interview that there was no RN coverage on those dates and that she was the only RN in the building, and the overall census was 107 residents. This deficiency was investigated under two complaint numbers.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present in the facility for at least eight consecutive hours a day, seven days a week, as required. Review of staffing schedules from 01/01/26 to 04/21/26 showed there was no RN coverage for at least eight consecutive hours on 01/24/26 and 04/05/26. Review of the staffing tool for 04/05/26 to 04/11/26, conducted with the Administrator, Human Resources staff, and the Scheduler/HR Assistant, confirmed there was no RN coverage for at least eight consecutive hours on 04/05/26. During interviews, the Administrator, HR staff, and Scheduler/HR Assistant verified that, based on the staffing schedules and staffing tool, the facility did not have RN coverage for at least eight consecutive hours on those two days, potentially affecting all 50 residents in the facility. Review of the facility assessment dated [DATE] showed that the staffing plan specified there would be two RNs and/or LPNs for each shift, but it did not address the requirement to ensure an RN was present for at least eight consecutive hours a day, seven days a week. This omission in the facility assessment, combined with the documented gaps in RN coverage, led to the cited deficiency, which was investigated under Complaint Numbers 2966092, 2667528, and 2650567.
Lack of Full-Time RN Director of Nursing and Inadequate Nursing Leadership Structure
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time Director of Nursing (DON) who is a registered nurse and to ensure that this position provided direct oversight of nursing services, as required. Review of staff schedules for a specified week showed that the interim DON, a registered nurse, was present in the facility for only 11 hours on one day and otherwise was only in the building one to two days per week since the prior DON was terminated in February. Interviews with the interim DON confirmed she was serving as DON at another building and only came to this facility intermittently, with a plan for the current Assistant DON, an LPN, to assume the DON role after completing RN school the following year. The facility census at the time was 44 residents. Multiple staff interviews corroborated that the facility did not have a full-time DON. The ADON, an LPN, reported that the previous DON had been terminated and that the interim DON only assisted once or twice a week, while a clinical RN was present in the building eight hours a day Monday through Friday but did not function as DON. Other LPNs and an RN confirmed that the interim DON was only in the facility one to two times a week and that staff brought issues to the ADON, who was not an RN. The Licensed Nursing Home Administrator verified there was no full-time DON and also stated there were no company job descriptions for the DON or ADON positions. Review of the facility assessment showed no DON listed among those completing the assessment, despite the document describing the DON as part of the interdisciplinary team and as a necessary staff classification to meet resident care and operational needs.
Failure to Maintain Required RN Coverage Due to DON Escorting Resident to Surgery
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a registered nurse (RN) was present in the facility for eight consecutive hours a day as required, affecting all 59 residents. Review of staffing schedules for 04/01/26 to 04/07/26 showed that the RN/Director of Nursing (DON) was scheduled for eight hours daily Monday through Friday. However, review of employment time punches for 04/06/26 revealed that no RN worked in the facility that day and that three LPNs each worked 12-hour shifts to care for residents. The facility’s policy on Sufficient Staffing, dated 01/2026, stated that a RN would serve as the DON and provide administrative oversight of nursing services consistent with regulatory requirements. Resident and staff interviews further clarified the circumstances leading to the deficiency. One resident reported that the DON had to accompany him to an outpatient surgical appointment on a Monday because there was a mix-up with times and the respiratory therapist could not go, and that the same situation occurred for another appointment on 04/02/26. The transportation coordinator stated that on 04/06/26 the DON left the facility with this resident at 10:00 A.M. for outpatient surgery in a bordering city about 40 minutes away, returned briefly to the facility for about 20 minutes after the surgical center confirmed a respiratory therapist did not need to stay, and then had to return to pick up the resident, with another staff member ultimately going to the surgical center after the coordinator’s shift ended. The DON confirmed she accompanied the resident to the surgical center on 04/02/26 and 04/06/26, verified that the staffing tool reflected incorrect hours for her on 04/06/26, and acknowledged she was not in the facility continuously for eight hours and that there was no RN in the facility that day. The administrator and a regional RN also verified that the employment punches for 04/06/26 did not show the required eight RN hours for facility coverage.
No RN Coverage for Required Daily Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least eight consecutive hours per day, seven days per week. Record review and staff interview showed that the facility did not have an RN on duty on 02/28/26. Review of the facility's Staffing policy dated 05/01/22 stated that the facility should maintain adequate staffing on each shift to ensure residents' needs and services are met. During an interview on 03/13/26 at 1:52 P.M., the Chief Operating Officer confirmed that the facility did not have an RN on duty in the facility on 02/28/26. Review of the Minimum Direct Care Daily Average of 2.50 survey tool for 02/27/26 through 03/05/26 also showed there was no RN coverage on 02/28/26.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to employ and have an actively working full-time Director of Nursing (DON). Review of staff clock-in times and resident records showed no documentation of an RN being in the building for eight consecutive hours on 02/21/26 or 03/08/26. The facility assessment dated 01/30/26 stated the facility must have a full-time DON, full-time Assistant DON (ADON), full-time wound care nurse, and full-time MDS nurse, but these positions were not filled or actively working in the facility during the survey period. Multiple staff interviews confirmed the absence of key nursing leadership and RN coverage. CNAs reported there was no DON, ADON, MDS nurse, or wound care nurse in the facility and that there was no nursing management available to report issues or concerns to. Human resources staff stated the previous DON gave a 30‑day notice but stopped working before the end of the notice period, and the ADON resigned effective immediately, leaving those positions vacant; positions for MDS nurse, wound care nurse, and ADON remained open. An LPN reported the facility was short on RN hours, that RNs were scheduled but often did not show up or quit, and that the situation worsened without a DON or ADON in the building. Other staff confirmed the facility was not meeting required RN hours, that RN names were placed on schedules and PPD sheets without the individuals being physically present, and that no corporate nurses came in to fill in for the DON or ADON.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required, potentially affecting all 107 residents. Review of staffing schedules and staff timecard punches for the period 12/25/25 through 12/31/25 showed that no RN worked in the facility on 12/25/25 and 12/31/25, despite census data indicating that 97 residents were in the facility on each of those days. During an interview on 02/24/26 at 3:18 P.M., the DON confirmed there was no RN coverage on those two dates and stated she was the only RN in the building on those days. This deficiency was investigated under Complaint Numbers 2671148 and 2603969. The deficiency centers on the absence of required RN coverage on specific days, as evidenced by staffing records, timecard punches, and census data, and confirmed by the DON’s interview, in the context of a facility census of 107 residents overall and 97 residents present on the days without RN coverage.
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