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F0727
E

Failure to Designate Full-Time RN as Director of Nursing

Wheat Ridge, Colorado Survey Completed on 06-12-2025

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 a registered nurse (RN) was designated as the full-time director of nursing (DON), as required. Record review showed that the facility's DON job description outlined essential administrative and supervisory functions, but the staff list provided did not identify anyone currently serving as the acting DON. The nursing home administrator (NHA) confirmed that there was no designated RN acting as the full-time DON at the time of the survey. Interviews with staff revealed that DON responsibilities were being shared among an LPN, the minimum data coordinator (MDSC), and a regional clinical resource (RCR). The LPN stated she was sharing DON duties with the MDSC and RCR, and the NHA confirmed that the facility had been without a full-time RN in the DON role for over a month. The MDSC, who is an RN, was also responsible for restorative therapy and MDS duties, and the RCR was not present in the building daily. Each of these roles was described as a full-time position, indicating that the DON responsibilities were not being fulfilled by a single, full-time RN as required.

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