Failure to Notify State Agency of DON Termination
Summary
The facility failed to provide written notice to the State agency responsible for licensing when their Director of Nursing (DON) was no longer employed. The facility's policy required a full-time DON, and the Facility Assessment Tool confirmed this requirement. The Nursing Schedule from 04/01/24 through 04/16/24 showed no documentation of a DON being scheduled or working during this period. The DON's Termination Notice indicated the last day worked was 03/29/24, with a termination date of 04/01/24. Observations confirmed that no DON was present in the facility from 04/09/24 through 04/16/24. During an interview, the Administrator admitted they had not notified the State agency about the DON's termination because they had not yet hired a replacement.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to timely notify the State Agency (SA) of a change in the DON position for a census of 85 residents. The DON began the role but the required change-of-DON application and written notice were not completed and mailed until weeks later, as confirmed by the DON’s and acting ADM’s interviews and the dated documents. The ADM reported being unaware of the required timeframe for notification, and SA records showed the DON application was received several days after it was mailed, delaying SA verification of the DON’s qualifications.
The facility did not update the state survey agency regarding changes in its administrative leadership, including an interim Administrator who served for several months and the current Administrator. A review of the EIDC website showed that these administrators were not listed as required, and the current Administrator acknowledged that the facility had failed to report these changes. This non-compliance affected all residents and was identified during a complaint investigation.
The facility did not provide written notice to the State Agency about a change in administrator, as the name listed in the TULIP system did not match the current ADM. Staff interviews confirmed the ADM had been in the role for several months, but the state records were not updated to reflect this change.
The facility did not notify the State Agency within the required five working days after a change in the DON, as confirmed by record review and administrator interview. This delay in notification had the potential to impact all residents in the facility.
The facility did not inform the State agency when a new Medical Director replaced the previous one, as confirmed by the Nursing Home Administrator during an interview.
The facility did not notify the State Agency within the required timeframe after a change in administrator. Staff interviews and document reviews confirmed the new administrator assumed the role, but there was no proof that the required notification was sent or received by the SA, and the previous administrator remained listed as active in the licensing system. There was also no facility policy for reporting such changes.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to provide timely written notice to the State Agency (SA) of a change in the Director of Nursing (DON) position for a census of 85 residents. The current DON reported in an interview that she began her role on 12/10/25 and that corporate staff requested her licensing information, but she did not know when the leadership change notification was sent to the SA. During a concurrent interview and record review, the acting Administrator (ADM) confirmed that the change-of-DON documents were dated and mailed on 1/7/26, rather than at the time the change occurred, and stated he was not aware of the time requirement for notification. A facility letter to the SA dated 1/7/26, signed by the DON the same day, referenced a “CHANGE OF DIRECTOR OF NURSING Application,” and SA database records showed the DON application was received on 1/13/26. This delay in notification postponed the SA’s verification that the DON was qualified to lead clinical services, which the report states had the potential to compromise resident safety and regulatory compliance for all 85 residents. The deficiency centers on the facility’s inaction in promptly notifying the SA of the DON change at the time it occurred, as required by rules on disclosure of ownership and administrative personnel changes. The DON’s start date, the later date of the application and mailing, and the ADM’s lack of awareness of the time requirement are specifically documented as the factors leading to the late reporting.
Failure to Notify State Agency of Administrator Changes
Penalty
Summary
The facility failed to notify the state survey agency of changes in administrative personnel, specifically changes in the Administrator position, affecting all 59 residents in the facility. Review of the Enhanced Information Dissemination and Collection (EIDC) website showed that neither the current Administrator nor the interim Administrator who served from November 2025 through January 2026 were listed as required. In an interview, the current Administrator confirmed that the facility had not informed the state survey agency of these changes in administrators, including the current Administrator. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791. No additional resident-specific clinical information, medical history, or condition at the time of the deficiency was provided in the report.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the facility's administrator. Record review of the TULIP system showed that the administrator listed did not match the current administrator (ADM) of the facility. Observations confirmed that the name posted in the facility as the administrator and abuse coordinator was not the same as the one recorded in TULIP. Interviews with the ADM revealed she had been serving as administrator since March 2023, but her name was not updated in the state system. Staff interviews further confirmed that the ADM was recognized as the administrator and abuse coordinator by employees, and the DON stated that the ADM had been the only administrator during her tenure. The ADM reported that she had completed the necessary form for the change and provided it to the previous owners, but the update was not made in TULIP. Review of the Facility Summary Report also showed a mismatch between the administrator's name and the ADM. No information about residents or their medical conditions was included in the report, and the deficiency centers solely on the failure to notify the State Agency of the change in facility administrator.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to notify the State Agency within five working days following a change in the Director of Nursing (DON), as required by licensure regulations. Record review showed that the DON was changed on 9/13/25, but the notification form was not faxed to the Department of Health and Human Services (DHHS) until 9/29/25, exceeding the required timeframe. During an interview, the Administrator confirmed that the notification was not submitted within the mandated five working days. This deficiency had the potential to affect all 68 residents residing in the facility at the time.
Failure to Notify State Agency of Medical Director Change
Penalty
Summary
The facility failed to notify the State agency of a change in its Medical Director at the time the change occurred. Review of facility data showed that Doctor Employee E1 was the Medical Director as of 1/1/20, but during an interview, the Nursing Home Administrator stated that Doctor Employee E1 was no longer employed and that Doctor Employee E2 became the new Medical Director effective 7/24/25. The Nursing Home Administrator confirmed during the interview that the State agency had not been informed of this change in Medical Director as required by regulations.
Failure to Timely Notify State Agency of Change in Administrator
Penalty
Summary
The facility failed to notify the State Agency (SA) within ten days of a change in administrator (CHOA) that occurred on 11/13/2023. Multiple staff interviews confirmed that the new administrator (ADM 1) assumed the role on that date, following the resignation of the previous administrator (ADM 2). Staff, including the DON, Medical Records Director, and Social Services Director, were aware of the change internally, but there was uncertainty and lack of knowledge regarding the external reporting requirements to the SA. The new administrator and the Vice President of Operations (VPO) both stated that the responsibility for reporting the change to the SA was understood, but neither could provide proof that the required notification was sent or received by the SA. A review of facility documents showed that the offer letter for ADM 1 was dated 11/13/2023, and the resignation letter from ADM 2 was effective 9/15/2023. The Applicant Individual Information (HS215A) form was completed and signed by ADM 1 on 12/30/2023, but there was no evidence of receipt by the SA. Both ADM 1 and the VPO stated that documents were mailed to the SA, but neither could provide proof of mailing or confirmation of receipt. Additionally, there was no facility policy or procedure for reporting changes of administrator to the regulatory authority. A review of the State Agency's Electronic Licensing Management System (ELMS) indicated that as of 12/11/2025, ADM 2 was still listed as the active administrator, with no end date, and the most recent CHOA application was pending as of 12/3/2025. There was no record of a CHOA application between 4/22/2022 and 12/3/2025. The California Code of Regulations requires written notification to the Department within ten days of a change in administrator, including the name and license number of the new administrator. The facility was unable to provide evidence that this requirement was met.
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