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F0727
F

DON Served as Charge Nurse During High Census

Odessa, Texas Survey Completed on 06-24-2025

Penalty

Fine: $366,050
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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 the Director of Nursing (DON) did not serve as a charge nurse when the average daily occupancy was 60 or more residents, as required by regulation. Review of the daily staffing schedule showed that the DON worked as a charge nurse on nine separate days during the review period. During an interview, the DON confirmed she had been working night shifts as the charge nurse due to a recent staff resignation and stated that no one else had been designated to perform her DON duties during these times. The DON also indicated she was unaware of the regulation prohibiting her from working the floor in this capacity. Additionally, when requested, the facility was unable to provide a policy for RN/DON coverage. The job description for the DON emphasized the need for knowledge of nursing home regulations and accountability for compliance, but also included a provision to augment floor staffing if needed. There were no details provided about specific residents or their conditions related to this deficiency.

See complete original report
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