Based on record review and staff interview the facility failed to ensure a new, current Registered Nurse waiver was completed. Resident Identifier: Facility:Facility. Facility Census: #28 Findings include: a) Registered Nurse Waiver On 01/07/26 at 11:00 AM observation of the Daily Staffing Report for the time period of 12/23/25 through 01/05/26 (14 days) finds there was not a Registered Nurse (RN) on duty for eight (8) consecutive hours daily as required. The facility employees four (4) Registered Nurses. They are the Director of Nursing (DON) (#28), The Assistance Director of Nursing (ADON) (#35) and two (2) part time Registered Nurses, #18 and #19. According to a review of the Employee Period Total Report, RN #19 did not work at all during the above time period. …
F731
Nursing and Physician Services Deficiencies
Request a waiver if it can't meet the nurse staffing requirements.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F731 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F731 finding.
The harm level
How severely F731 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D— | E116.7% | F466.7% |
| No harm, potential for minimal | A— | B— | C116.7% |
In the surveyor’s words
What an F731 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and document review, the facility failed to ensure residents, resident representatives, and resident's immediate family members were notified of the facility's waiver for the seven-day Registered Nurse (RN) requirement for 22 of 22 residents residing in the facility. This deficient practice had the potential for residents to not be aware of the staffing waiver indicating the facility did not have RN coverage in the facility seven days a week. Findings include: The facility waiver for the seven-day RN requirement, dated 04/16/2021, documented the facility would notify residents of the facility (or responsible guardians or legal representatives) and members of their immediate families of the waiver. …
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