Failure to Timely Report Changes in Administrator and DON to State Agency
Summary
The facility failed to provide written notice to the State Agency regarding changes in key administrative personnel, specifically the Administrator and Director of Nursing (DON). The new Administrator began her role on 3/10/25, and the new DON started on 3/15/25. However, these changes were not updated in the Health Care Facility Reporting System (HCFRS) as required. The last reported changes in the system were for the Administrator on 12/6/24 and for the DON on 5/23/24, with no indication that the previous individuals were no longer employed or that new personnel had assumed these roles. During interviews, the Administrator acknowledged that the changes were not yet reflected in the HCFRS and stated that the process was ongoing. It was revealed that the previous management company had indicated they would update the system but did not do so, and some staff from the prior company who still had access also failed to report the changes. Both the current Administrator and DON recognized that it was their responsibility to ensure the updates were made in the reporting system, but this was not completed as required.
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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