Belleview Valley Nursing Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with physician orders for six residents (Residents #4, #5, #6, #34, #41, and #69) out of 18 sampled residents. The facility also failed to ensure the Hospice Coordinated Plan of Care addressed necessary treatments, supplies, and appliances for two residents (Residents #3 and #27) out of three sampled residents receiving hospice services. These failures had the potential to result in delayed treatment, ineffective symptom management, uncontrolled blood glucose levels, and compromised continuity of care. The facility census was 77. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for three residents (Residents #4, #21, and #81) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of three sampled residents. The facility's census was 77. Review of the facility's policy titled, Policy and Procedure PTSD, dated 03/26/26, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an infection prevention and control program to prevent the transmission of infectious organisms. The facility failed to follow Enhanced Barrier Precautions (EBP - precautions used during high-contact resident care activities for residents infected or colonized with a multidrug-resistant organism (MDRO - microorganisms resistant to one or more classes of antimicrobial agents) or for residents with chronic wounds and/or indwelling medical devices) for one resident (Resident #2) out of four sampled residents. The facility failed to perform appropriate hand hygiene and glove changes during incontinent care for two residents (Residents #50 and #76) out of five sampled residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving one resident (Resident #76) out of five sampled residents exposed during incontinent care and emptying of a urinary catheter (a sterile tube inserted into the bladder to drain urine) drainage bag. The census was 77. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for one resident (Resident #3) out of 18 sampled residents. The facility census was 77. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure placement of the urinary catheter (a sterile tube inserted into the bladder to drain urine) drainage bag was maintained for two residents (Residents #2 and #76) out of four sampled residents. The facility census was 77. [...]

Inspectors wroteThe facility failed to ensure care and services for one resident (Resident #59) out of a sample of one resident with a colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall) were provided in accordance with professional standards of practice. The facility allowed Resident #59 to independently perform colostomy care without evidence of a physician order authorizing self-administration of care, without a documented assessment of the resident's competency to safely perform colostomy care, and without ongoing nursing assessment and monitoring of the stoma (opening) and appliance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and/or disposed of after the expiration date in accordance with currently accepted practices. This had the potential to affect all residents. The facility census was 77. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 81. The facility did not provide a dietary cleaning rotation or food storage policy. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. The facility census was 81. The facility did not provide a maintenance policy. 1. Observation of the bathroom door in room [ROOM NUMBER] on 12/03/25 at 10:49 A.M., showed a 6 inch (in.) by 3 in. hole. During an interview on 12/03/25 at 10:49 A.M., the resident in room [ROOM NUMBER] said the hole in the bathroom door had been there since he/she moved into the room about three months ago. He/She spoke with the Maintenance Director about his/her concerns with the room because it was frustrating. 2. Observations on 12/08/25 at 9:30 A.M. and 3:45 P.M., showed:- The A hall dining room area wooden food service counter behind the steam table with an approximate 2 foot (ft.) by 6 in. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice when physician orders were not followed for two residents (Residents #1 and #70) out of 18 sampled residents. The facility's census was 81. The facility did not provide a policy on following physician's orders. 1. Review of Resident #1's Physician Order Sheet (POS), dated 12/08/25, showed:- An order for a urinalysis (UA - a group of laboratory tests to examine urine) with a culture and sensitivity (C&S - a laboratory test that identifies germs causing an infection and which antibiotics will be most effective against them) one time only for burning, urgency and frequency for three days. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance and Improvement Program (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee meetings with the required members. The facility census was 81. Review of the facility's policy titled Quality Assurance and Improvement Program (QAPI), dated 05/31/24, showed:- The primary purpose of the QAPI program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life, and clinical outcomes of our residents;- Members of facility management are accountable for QAPI efforts;- The QAPI Committee will include at minimum: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) and follow appropriate infection control practices with hand hygiene and glove changes, when staff performed wound care for one resident (Resident #70) out of two sampled residents, during incontinent and oxygen care for two residents (Residents #5 and #17) out of two sampled residents, catheter care for two residents (Residents #3 and #74) out of two sampled residents, and hand hygiene during medication administration for two residents (Residents #46 and #73) out of seven opportunities. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) assessment within 14 days of admission to hospice services for one resident (Resident #5) out of two sampled residents. The facility census was 81. The facility did not provide a policy regarding the completion of significant change MDS assessments. 1. Review of Resident #5's medical record showed:- admitted to the facility on [DATE];- admitted to hospice services on 08/22/25. Review of the resident's significant change MDS, dated [DATE], showed: - Received hospice services;- The facility did not complete a significant change MDS within 14 days of the resident's admission to hospice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure urinary indwelling catheter (a tube inserted into the bladder to drain urine) tubing was maintained in the proper position and failed to cover the catheter drainage bag with a dignity bag for one resident (Resident #74) out of three sampled residents. The facility census was 81. Review of the facility's policy titled, Catheter Care, undated, showed:- Keep the bag below the level of the resident's bladder at all times;- Use a catheter bag cover to protect the resident's dignity;- The policy did not address proper positioning of the catheter tubing. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide packed lunch/snacks for one resident (Resident #72) while at dialysis (a process for removing waste and excess water from the blood) center out of one sampled resident. The facility census was 81. The facility did not provide a policy for dialysis care. 1. Review of #72's medical record showed:- admitted on [DATE];- Diagnoses of chronic kidney disease stage 5 (kidneys have failed or are very close to failing, unable to filter waste and fluid effectively, requiring dialysis) and essential hypertension (high blood pressure);- Cognition intact. Review of the resident's Care Plan, revised 11/16/25, showed:- The resident needs dialysis related to kidney failure;- The resident receives dialysis three times per week on Tuesday, Thursday, and Saturday at the dialysis center. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and to ensure the resident environment was free from accident hazards for one resident (Resident #1), who had been assessed as needing supervision for smoking, was observed smoking in his/her room on several occasions while receiving supplemental oxygen via a nasal cannula, and failed to investigate the source of the smoking materials (lighters and cigarettes). The resident sustained 2nd degree burns while smoking in his/her room, putting the entire building and its occupants in danger. The facility census was 86. The administration was notified on 10/20/25 at 4:55 P.M. of an Immediate Jeopardy (IJ) which began on 10/13/25. The IJ was removed on 10/21/25, as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all residents residing in the facility. The facility census was 91. Review of the facility's policy titled, Nursing Staff, undated, showed: - The facility must use a RN for at least eight consecutive hours a day, seven days a week. Review of the facility's Facility Assessment Tool, last reviewed 07/09/24, showed: - Did not address RN staffing. Review of the Center for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data Report from the Community Assessment for Public Health Emergency Response (CASPER) REPORT 1705D for the fiscal year quarter 1, 2025 (October 1, 2024 to December 31, 2024) showed: - Triggered four or more days within the quarter with no RN hours; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility's census was 91. The facility did not provide a policy for a safe, clean, and comfortable homelike environment. 1. Observation on 04/14/25 at 11:01 A.M., of Room A15 showed: - No cover over two fluorescent bulbs in the light fixture above the bed next to the door. 2. Observation on 04/17/25 at 9:51 A.M., of the A Hall shower room showed: - A 2 ft. x 2 ft. vent with a build up of dust and debris next to the right side of the shower stall; - The shower stall with a large floor area with 108 missing tiles and a rigid floor surface; - A large floor area of the shower stall with rusty, brown-colored stains and a build up of dirt and grime; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the statement of appeal rights or the name, address, or telephone number of the office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) within the transfer and discharge notices for six residents (Residents #18, #35, #46, #47, #54, and #62) out of seven sampled residents. The facility's census was 91. Review of the facility's policy titled, Discharges, undated, showed: - The facility must ensure the discharge is documented in the resident's medical record, including Physician's order for the discharge, basis for the transfer, specific resident needs that can't be met; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) assessment within 14 days of admission to hospice services for four residents (Residents #1, #34, #47, #52) out of four sampled residents. The facility census was 91. The facility did not provide a policy regarding the completion of significant change MDS assessments. 1. Review of Resident #1's medical record showed: - admitted to hospice services on 03/18/25; - No significant change MDS dated on or after 03/18/25; - The facility failed to complete a significant change MDS within 14 days of the resident's admission to hospice. 2. Review of Resident #34's medical record showed: - admitted to hospice services on 12/27/24; - No significant change MDS dated on or after 12/27/24; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide infection prevention precautions by not following enhanced barrier precautions (EBP) for two residents (Residents #18 and #29) out of two sampled residents. The facility also failed to correctly screen three residents (Residents #18, #29, and #138) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents required by state regulation 19 CSR 20-20.100. The facility's census was 91. Review of the facility's policy titled, Enhanced Barrier Precaution Policy and Procedure, dated August 2024, showed: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain essential equipment in a safe and operable working condition. This deficient practice had the potential to affect all residents. The facility census was 91. The facility did not provide a policy for equipment maintenance. Review of the facility's Maintenance Request showed: - On 09/09/24, the top right dryer not working. Would have to reiterate to corporate about parts needing ordered; - On 11/14/24, washer #2 (left) didn't work, trips the fuse when powered on or during a cycle. Needed cleaned and investigated. Corrected Action: Replaced the computer and door latch sensor and still threw the door code. Called and called the washers technician line and was now waiting for a call back with advice on the problem; - On 01/13/25, right washer with a code of F8 for slow drain. Corrected Action: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the insect population in the facility. The facility census was 91. The facility did not provide a policy on pest control. Review of the facility's Pest Control Invoices for 2025 showed: - No service invoices for January and February 2025; - March 2025 service targeted the German roach and the house mouse; - No services targeted flies. 1. Observation on 04/14/25 at 11:01 A.M., of Room A15 showed: - Six flies flew around the room. During an interview on 04/14/25 at 11:05 A.M., the resident in Room A15 said he/she kept a fly swatter hung on the wall near the bed so that he/she could try to kill the flies in the room. The flies got really bad, it was frustrating, and didn't feel clean, because they landed on the urinal and on the bedding. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a final accounting of resident personal funds within 30 days of discharge for one resident (Resident #250) of three sampled residents and failed to refund resident funds within 30 days of when a resident expired for one resident (Resident #95) outside the sample. The facility census was 91. Review of the facility's policy titled, Policy and Procedures for Maintaining the Resident Trust Fund Account, undated, showed: - Required by law to submit a written account of the remaining personal funds for any deceased resident who has received aid, care, assistance or services paid by the Department of Social Services; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently document a resident's code status with cardiopulmonary resuscitation (CPR- an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) or Do Not Resuscitate (DNR - does not want CPR) for two residents (Residents #21 and #52) out of 19 sampled residents. The facility census was 91. Review of the facility's policy titled, Advanced Directives, undated, showed: - The facility will provide to each resident or surrogate his/her rights under State law to formulate advance directives. The facility is permitted to contract with other entities to furnish this information but is still legally responsible. The facility will document in a prominent part of the resident's current record whether or not the resident has executed an advance directive; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for two residents (Residents #138 and #288) out of seven sampled residents. The facility's census was 91. Review of the facility's policy titled, Care Plan Completion, undated, showed: - The facility will develop and implement a Baseline Care Plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care; [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and obtain physician's orders for wound care for one resident (Resident #25) out of three sampled residents. The facility also failed to ensure staff followed professional standards of practice when staff did not follow through with the collection of urine and report lab results in a timely manner for two residents (Residents #35 and #138) out three sampled residents. The facility census was 91. Review of the facility's policy titled, Skin Conditions, undated, showed: - Did not address when staff should obtain physician orders for wounds or skin conditions. Review of the facility's policy titled, Laboratory Services, undated, showed: - The facility will provide or obtain laboratory services to meet the needs of its residents, and will promote practices to ensure the quality and timeliness of laboratory services; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide ongoing skin assessments, perform and document treatments, and monitor progression of a pressure ulcer (areas of localized damage to the skin and underlying tissue generally the result of pressure, shear, and/or friction) for two residents (Residents #1 and #18) out of three sampled residents. The facility census was 91. Review of the facility's policy titled, Pressure Ulcers, undated, showed: - The facility will ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition indicates that they were unavoidable; - The facility will ensure that all residents at risk for pressure ulcers are identified to be at risk and given care to prevent the development of pressure ulcers. See the policy: Skin Assessment; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement protective measures for smoking and failed to accurately complete a smoking assessment per facility policy for one resident (Resident #1) out of three sampled residents. The facility census was 91. Review of the facility's policy titled, Smoking, undated, showed: - The smoking supervising staff member will hand out and light the residents' cigarettes and supervise the safety of the residents during smoking. Will notify the Unit Nurse when a resident's ability to smoke safely is in question; - On admission the Unit Nurse will assess the resident's ability to smoke safely by completing a smoking assessment that includes an evaluation of the resident's safety awareness, judgement, cognitive ability, and manual dexterity; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for recommendation made by the registered dietician (RD) for two residents (Residents #1 and #18) out of three sampled residents. The facility census was 91. The facility did not provide a policy regarding RD recommendations. 1. Review of Resident #1's medical record showed: - admitted on [DATE]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for three residents (Residents #52, #62, and #81) out of seven sampled residents, with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). The facility's census was 91. Review of the facility's policy titled, PTSD, undated, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to document pertinent education and consent or declination of the influenza (a viral respiratory infection) vaccine was provided to the resident or the resident's representative, and failed to document the administration or declination of the influenza vaccine for three residents (Residents #29, #54, and #138) out of five sampled residents. The facility's census was 91. Review of the facility's policy titled, Influenza Vaccine, undated, showed: - The facility will offer an influenza immunization to every resident and staff member each year at the beginning of flu season October I through March 31; - The Infection Control Nurse will: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate facility-initiated discharge notice, failed to provide an appropriate discharge plan prior to providing the discharge notice, failed to reassess a resident's status after being discharged from an acute care hospital, and refused to allow one resident (Resident #1) to return to the facility. The sample size was five residents. The facility census was 80. Record review of the facility's undated Discharge Policy showed: 1. The facility must permit each resident to remain in the facility, and not discharge the resident from the facility unless: - The resident's welfare and needs cannot be met in the facility; - The resident's health has improved sufficiently so no longer needs services provided by the facility; [...]

Inspectors wroteRefer to Event ID J4LN14 for SOD as F600 is part of uncorrected survey visit. This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 07/18/24, and 09/20/24. Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #2 and #4) were free from physical abuse when Resident #1 physically assaulted Resident #2 and Resident #4 in two separate incidents. Resident #2 was knocked out of his/her wheelchair, hitting their head on the brick building, and requiring an x-ray of their knee. Resident #4 was punched in the face, knocking the resident over with their walker, and requiring them to sent to the hospital for an evaluation for injuries and pain. The facility census was 82.

Inspectors wroteRefer to Event ID J4LN13 for SOD Complaint #MO241216 This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 07/18/24. Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #8) was free from physical abuse when Resident #7 punched Resident #8 in the back of the head after an earlier verbal altercation. This resulted in Resident #8's head going forward and smacking his/her face into the medication cart. This caused bruising and swelling to Resident #8's cheek bone. The facility census was 83.

Inspectors wroteRefer to Event ID J4LN13 for SOD. Complaint #MO241561 and 241643 This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 04/16/24 and 06/11/24. Based on observation, interview and record review, the facility failed to ensure staff followed professional standards of practice when staff did not check on one resident (Resident # 6) out of six sampled residents for over seven hours on the night shift. The resident had fallen around midnight and lay on the floor of his/her bedroom until staff entered the resident's room at 6:55 A.M. The facility also failed to identify, assess, and care plan interventions related to falls. The facility census was 83.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one resident (Resident #2) was free from physical abuse, and 11 other vulnerable residents at an increased likelihood for abuse to occur when facility staff placed residents with a history of physical and verbal altercations and unstable, aggressive behaviors towards other residents, on the secured unit which housed 12 residents with dementia, receiving hospice care, or requiring total care from staff. The aggressive residents were placed on the secured unit for 24 hours to 5 days until the administrator felt they were no longer a risk to residents outside the locked unit. Resident #1 was placed on the secured unit after returning from a hospital evaluation due to physical aggression. Resident #1 got in an altercation with Resident #2, a resident on the secured unit for safety and dementia care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three residents (Residents #3, #4, and #5) of 10 sampled residents were free from involuntary seclusion. The facility failed to have a policy or system in place to identify clinical criteria for placing a resident in a secured/locked area. The facility failed to ensure placement on the unit was not for staff convenience or discipline. The facility to document clinical criteria in the resident's record for placement on the secured unit and ensure the resident's physician and members of the interdisciplinary team were involved in the assessment. The facility census was 88. 1. Record review of the facility undated Abuse policy showed: - The facility will ensure that each resident is free from abuse, neglect, misappropriation of resident property, and exploitation. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate facility-initiated discharge notice, failed to provide an appropriate discharge plan prior to providing the discharge notice, failed to reassess a resident's status after being discharged from an acute care hospital, and refused to allow the resident (Resident #1) to return to the facility out of three sampled residents. The facility census was 88. The facility did not provide a policy regarding transfers and discharges. 1. Review of Resident #1's Pre-admission Screening/Resident Review (PASRR) Level II Evaluation, dated 08/10/22, showed: - The resident's needs could be met in a nursing facility; - The resident did not need specialized services beyond those typically provided by a nursing facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents were free from abuse when the maintenance supervisor (MS) grabbed the arm and wrist of one resident (Resident #91) out of 20 sampled residents. The resident had a history of mental health support needs, including behavioral problems. During a behavioral episode, the MS grabbed the resident's arms/wrists and struggled to physically restrain the resident which resulted in bruising to the resident's right upper arm. The facility failed to take appropriate steps to protect the resident from additional abuse and allowed the MS to continue to work around the residents. The facility census was 96. The administrator was notified on 04/09/24 at 9:50 A.M., of an Immediate Jeopardy (IJ) which began on 04/03/24. The IJ was removed on 04/10/24, as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate an allegation of staff to resident abuse and failed to implement interventions to prevent further abuse from occurring for one resident (Resident #91) out of 20 sampled residents after the Maintenance Supervisor (MS) grabbed the resident's arm and wrist in a restraining manner that resulted in a physical struggle and bruising to the resident's right upper arm. The facility also failed to follow their policy, resulting in the MS continuing to work around the resident. The facility census was 96. The administrator was notified on 04/09/24 at 9:50 A.M. of an Immediate Jeopardy (IJ) which began on 04/03/24. The IJ was removed on 04/10/24, as confirmed by surveyor onsite verification. Review of the facility's abuse policy, undated, showed: - Ensure that each resident is free from abuse; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the Coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for COVID-19. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was on duty 40 hours per week and to ensure a Director of Nursing (DON) worked full time. This deficiency had the potential to affect all residents. The facility census was 93. Review of a request for a waiver of nurse staffing requirements from the Centers for Medicare and Medicaid Services (CMS) showed a letter, dated 02/15/23, with waiver approved effective February 15, 2023, through February 14, 2024. The waiver included the following requirement: - The facility has one full-time registered nurse regularly on duty 40 hours a week. This may be the same individual or part-time individuals. This nurse may or may not be the DON and may perform some DON and some clinical duties if the facility so desires. [...]