From November 30 through December 20, the nursing home failed to ensure licensed nurses served as charge nurses during any tour of duty across all 21 days. Federal regulations require facilities to have a licensed nurse in charge of each shift except when specifically waived by state authorities.
The facility's nursing home administrator admitted the staffing violations during a December 31 interview with state inspectors. "We changed the process for our staffing, we will be collecting actual hours using punch timecards," the administrator said at 10:14 a.m.
The administrator also confirmed that information the facility had submitted to federal regulators was wrong. The facility reports staffing data to the Payroll-Based Journal system, which Medicare uses to calculate star ratings and inform families about nurse staffing levels.
During a follow-up interview three minutes later, both the administrator and director of nursing confirmed the facility had failed to designate licensed charge nurses for the entire 21-day period.
The violation covers every shift during those three weeks. Licensed nurses serve as charge nurses to oversee patient care, supervise nursing assistants, and ensure medical needs are met around the clock.
State inspectors classified the violation as having "minimal harm or potential for actual harm" but noted it affected "many" residents. The finding represents a fundamental breakdown in the facility's nursing supervision structure during a period spanning Thanksgiving and leading up to Christmas.
The facility must submit a correction plan to maintain its participation in Medicare and Medicaid programs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Concordia At Rebecca Residence from 2025-12-31 including all violations, facility responses, and corrective action plans.