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:
Failure to Notify State Agency of Interim DON Change: The facility did not provide written notification to the State Agency when the ADON assumed the role of Interim DON. The Interim DON stated he had been performing DON duties and had not submitted any required forms, while the Operations Manager said the facility believed notification was not needed until a permanent DON was hired. The State Agency database did not show receipt of a DON application.
Failure to Notify State Agency of DON Change: The facility did not provide written notice to the State Agency when the DON position changed. The interim DON had started in the role and signed the HS 215A form, but the form had not been submitted, and the State Agency database did not show receipt of the DON application.
Failure to notify the State Agency of a change in the facility administrator was identified when the administrator name in TULIP and the Facility Summary Report did not match ADM A. Staff interviews confirmed ADM A had been serving as administrator for more than 30 days, with one staff member stating he had been in the role for months, yet written notice to the State Agency was not provided at the time of the change.
Failure to Provide Disclosure of Ownership: The facility failed to present the Disclosure of Ownership during the extended survey. The AO stated the responsible department was closed and the document would be emailed later, but it had not been provided by the time of the survey exit.
The facility failed to notify the State agency when the DON went on leave and an Interim DON assumed the role. Review of the Employee Information Sheet and an interview with the CNO confirmed the change was not reported when it occurred, resulting in a citation under 28 PA Code 201.14(a), Responsibility of licensee.
The facility did not submit required written notice to the State Agency when a new ADM and a new DON assumed their positions. The DON reported starting in the role recently and confirmed she had not filed the Centralized Applications Branch (CAB) application and had not been informed of CAB expectations, while the ADM believed the DON was responsible for the application. The ADM also stated he had been in his role for several months and believed the corporate office should have submitted the change-in-ADM application. State Agency database review showed no applications received for either position, delaying verification of the ADM and DON qualifications for oversight of clinical services for 109 residents.
Failure to Notify State Agency of Interim DON Change
Penalty
Summary
The facility failed to provide written notification to the State Agency when the Assistant Director of Nursing assumed the role of Interim Director of Nursing. The Interim DON stated that he began performing all DON responsibilities effective 6/29/26 and had not completed, signed, or submitted any forms or documentation related to the required reporting of his appointment. He also stated that notifying the State Agency of a change in the DON position was important so the agency could identify the individual serving as the primary clinical nursing leader and verify that the person in the role had the qualifications needed to oversee the facility’s clinical operations. The Operations Manager stated that the ADON assumed the role of Interim DON effective 6/29/26, but the facility had not submitted any notification or application to the State Agency because it believed submission was not required until a permanent DON was hired. The Operations Manager acknowledged uncertainty about the regulatory process for reporting an Interim DON and confirmed that the facility was waiting to hire a permanent DON before making any notification. A review of the State Agency database did not indicate that a DON application had been received from the facility, and the facility-provided job description for Director of Nursing listed the position as responsible for directing overall nursing services and requiring a valid state RN license in good standing.
Failure to Notify State Agency of DON Change
Penalty
Summary
The facility failed to provide written notice to the State Agency at the time of a change in the Director of Nursing position. The current DON started in the interim DON role on 6/26/26, but as of 7/9/26 the facility had not reported the change to the State Agency for a census of 104 residents. During an interview, the Administrator stated the facility had a new interim DON and had paperwork for the notification of change, HS 215A. During interviews and record review on 7/9/26, the DON stated she began working at the facility on 6/26/26 as the interim DON and confirmed she signed the HS 215A form on 7/8/26. The DON stated she was aware of the state requirement to submit the application. The Administrator confirmed the form had not been submitted to the State Agency, and stated it was important to submit the form to notify the State Agency of who managed the facility. A review of the State Agency database did not indicate the DON application was received from the facility.
Failure to Notify State Agency of Administrator Change
Penalty
Summary
The facility failed to provide written notice to the State Agency responsible for licensing the facility when there was a change in the facility administrator. Based on observation, interviews, and record review, the administrator listed in TULIP during offsite preparation on 6/26/2026 did not match ADM A, and the Facility Summary Report also showed an administrator name that did not match ADM A. During interviews on 6/27/2026, LVN D stated that ADM A was the administrator and had been for a while. DON B stated that ADM A had been the administrator for more than 30 days. ADON C stated that ADM A had been the administrator for at least a couple of months, maybe even 10 months or longer, and that he was on vacation and not available. In a later interview, DON B stated that ADM A had completed the name change in TULIP, but she did not think he was currently available.
Failure to Provide Disclosure of Ownership
Penalty
Summary
The facility failed to present a Disclosure of Ownership during the extended survey. On 06/04/26 at 10:18 AM, the Disclosure of Ownership document was requested from the Administrative Officer (AO). During the exit conference on 06/06/26 at 6:00 PM, the AO stated that the department responsible for completing and providing the Disclosure of Ownership document was closed and that the document would be emailed on Monday. As of 06/10/26 at 5:30 AM, the facility had not provided the Disclosure of Ownership document.
Failure to Report Change in DON
Penalty
Summary
The facility failed to notify the State agency of a change in its Director of Nursing at the time the change occurred. Review of the facility-provided Employee Information Sheet on 5/27/26 at 11:45 a.m. showed that the Director of Nursing began a leave on 5/14/26. During an interview on 5/27/26 at 12:00 p.m., the Chief Nursing Officer confirmed that the facility did not notify the State Agency when the Interim Director of Nursing assumed the position on 5/14/26. The deficiency was cited under 28 PA Code: 201.14(a), Responsibility of licensee.
Failure to Notify State Agency of Changes in ADM and DON
Penalty
Summary
The facility failed to provide required written notice to the State Agency (SA) regarding changes in key administrative personnel, specifically the Administrator (ADM) and the Director of Nursing (DON). The current DON began working in the DON position on 4/21/26, but the facility did not submit the necessary application to the Centralized Applications Branch (CAB), the SA unit responsible for reviewing licensure and certification-related transactions. In an interview, the ADM stated he did not think the CAB application for the new DON had been completed and indicated that the DON was responsible for completing it. In a separate interview, the DON confirmed she had started working at the facility eight days prior, had not filed the CAB application, and stated she was not informed about CAB expectations, indicating a lack of clarity about responsibility for regulatory notification. The facility also failed to notify the SA of the change in the ADM position. During an interview, the ADM reported he had been working at the facility since August 2025 and stated that the change-in-ADM application should have been completed and sent to CAB by the facility’s corporate office at that time. A review of the SA database showed no record of receiving an application for either the DON or the ADM from the facility. These failures delayed the SA from verifying that the ADM and DON were qualified to lead clinical services for a census of 109 residents and from confirming compliance with federal and state regulations.
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