Failure to Timely Notify State Agency of DON Change
Penalty
No penalty information released
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 notify the Department of Health and Human Services (DHHS) within 5 working days regarding a change in the Director of Nursing (DON) position, as required by licensure regulations. Record review showed that the previous DON's service ended on 2/2/2024 and the new DON began on 2/3/2024, but DHHS did not receive notification of this change until 3/31/2025. Interviews with the DON confirmed that the notification was not sent within the required timeframe and that the service dates should have been recorded as 2025. This lapse had the potential to affect all residents in the facility, which had a census of 50 at the time.