Failure to Notify State Agency of DON Changes
Summary
The facility failed to notify the State agency responsible for licensing about changes in their Director of Nursing (DON) position. The facility's assessment indicated that the DON should work five days a week for eight hours, and a Registered Nurse (RN) should cover when the DON is unavailable. However, records showed that RN I was hired as the DON in June 2022 and terminated in May 2023, while RN J was hired in November 2023 and terminated in December 2023. The last documented change of DON form was from July 2022, indicating RN I's employment. Nursing schedules from April to July 2024 showed no documentation of a DON being scheduled or working, with 107 days missed. During an interview, the Administrator confirmed that the facility had not had a DON since November 2023.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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 failed to notify the state agency of five changes in the Administrator role and five changes in the DON role over a specified period. This non-compliance was confirmed through a review of records and an interview with the current Administrator, affecting all 65 residents.
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 Administrative Changes
Penalty
Summary
The facility failed to notify the state agency of changes in administration and Director of Nursing (DON) positions. Specifically, there were five changes in the Administrator role and five changes in the DON role between 01/01/23 and 03/28/24. The facility did not report these changes to the state agency as required. This deficiency was confirmed through a review of facility records and an interview with the current Administrator, who acknowledged the failure to report these changes. This non-compliance had the potential to affect all 65 residents residing in the facility.
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