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F0839
F

Lapse in NHA Licensing Due to Expired Temporary Permit

Windsor, Colorado Survey Completed on 07-15-2025

Penalty

No penalty information released
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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 that professional staff were licensed, certified, or registered in accordance with applicable state laws. During the survey, it was found that the DON was acting as the nursing home administrator (NHA) while the facility had a NHA in training preparing to become the permanent licensed NHA. A review of the state licensing website revealed that the DON had applied for a temporary NHA license for emergency situations, but this permit had expired. There was a lapse in the NHA licensing, as the temporary permit was not renewed in time, resulting in a period where the acting NHA was not properly licensed. Interviews with the DON and the corporate operations director confirmed that the DON's temporary NHA license had expired and that there was no evidence the State Survey Agency was notified of the change in the NHA position. The corporate operations director believed that the licensing and regulatory agency would notify the State Survey Agency, but could not provide documentation to support this. Documentation later provided by the DON confirmed the lapse in licensing for the acting NHA.

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